Financial Policy. Pup’s may be checked in and checked out at any time during operating hours. If pup are checking in prior to 5PM, a full day of enrichment will be charged of $35.00. If pup’s are checked out after 12PM, a half day of enrichment will be charged of $25.00.
Financial Policy. Your payment is expected in FULL at the time services are rendered. Payment should be paid when checking-in to your appointment, prior to receiving any treatment. It is the patient’s responsibility to notify us if there is a change in insurance plan(s) and or benefits. If you choose to pay by check and your check is returned by your financial institution for ANY reason, you will be responsible for a $30 service charge in addition to the amount of the returned check. Should your account become delinquent for more than 60 days, a finance charge of $50 or 5% per month will apply, whichever is greater. If your account should be referred to an attorney or collection agency, the undersigned shall be responsible for ALL additional fees incurred in the collection process.
Financial Policy. I agree to assign insurance benefits to The Maryland Pediatric Group, LLC/Pediatric Consultants, P.A. whenever necessary. initial • I agree to pay copayments, coinsurance, deductibles, services not covered by insurance and any outstanding patient balances (if applicable) PRIOR to being seen by a provider. initial • I agree to pay in full in the event the provider does not participate with my insurance plan initial. • I agree that I am responsible for providing a current referral form at the time of service (before services are rendered) initial. • I agree that if it becomes necessary to forward my account to a collection agency because of lack of payment on legitimate patient balances owed to the practice, in addition to the amount owed, I also will be responsible for the fee charged by the collection agency for costs of collections. initial • I acknowledge the same responsibility for the siblings of the above mentioned patient. initial Other children seen at this office: Name: Date of Birth: Name: Date of Birth: Name: Date of Birth: Signature of patient, responsible parent, guarantor/legal guardian, insured and/or authorized representative:
Financial Policy. The overall financial policy of the Company shall be based on a definitive budget, which shall be approved by the Parties on an annual basis (the “Budget”). The initial Budget is attached to this Agreement as Exhibit G. In accordance with the Budget, the activities and any expansion of the Company shall be financed from its own resources and, if required, from additional equity funding or shareholders loans made by the Parties, which the Parties agree to provide to the Company from time to time as necessary. The Parties undertake to provide a shareholders loan for an amount of € [*] per each Party within one month from the establishment of the Company.
Financial Policy. Thank you for choosing our practice as your healthcare provider. We are committed to building a successful physician-patient relationship with you and your family. Your clear understanding of our Patient Financial Policy is important to our professional relationship. Please understand that payment for services is a part of that relationship. Please ask if you have any questions about our fees, our policies, or your responsibilities. It is your responsibility to notify our office of any patient information changes (i.e. address, name, insurance information, etc). Co-Pays and Deductibles All copayments, deductibles, and past due balances are due at time of check-in unless previous arrangements have been made with a billing coordinator. We accept cash, check, or credit cards. Absolutely no post-dated checks will be accepted. Insurance Claims Insurance is a contract between you and your insurance company. In most cases, we are NOT a party of this contract. We will bill your primary insurance company as a courtesy to you. In order to properly bill your insurance company, we require that you disclose all insurance information including primary and secondary insurance, as well as any change of insurance information. Failure to provide complete insurance information may result in patient responsibility for the entire bill. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility and benefits. If your insurance company does not pay for any of your services performed at our office, you may be responsible for the complete balance of the non-payable services. If we are out of network with your insurance company and your insurance pays you directly, you are responsible for payment and agree to forward the payment to us immediately.
Financial Policy. Initial/ I acknowledge that I have read and understand the financial policies of this office.
Financial Policy. The following information pertains to the practice's financial policy. We hope this will answer any questions you may have, but if you have any questions or special concerns please do not hesitate to discuss them with us at the first session. Please acknowledge your understanding of this policy by signing at the end of this form. If you would like a copy of this form for your records, we will be happy to provide one for you.
Financial Policy. Licensee q shall q shall not charge or collect a fee in the form of admission or registration fees or collect donations.
Financial Policy. Thank you for choosing Montgomery Vascular Surgery for your medical care. Please understand that our service agreement is with YOU and NOT your insurance company. Just as you have chosen your insurance coverage, you are responsible for payment for the service(s) rendered and claims are filed as a courtesy by our office.
Financial Policy. If you are a Self-Pay patient we will collect full payment at the time of service. We do offer a discount if you are an existing patient with us, provided your family has a zero balance. If you are unable to meet your payment obligations we can reschedule your appointment to a more suitable time. We appreciate your understanding. PAYMENT METHODS • AALFA Family Clinic accepts cash, checks, and major credit cards (VISA, MC, DISCOVER) for any amount greater than $10. Charges under $10 must be paid in cash. Patients are responsible for an additional payment of $35 for any returned funds.
