Please read the following. (a) In order to facilitate pooling of the assets in all sub accounts, it is required that all deposits must be made in cash. The trust does not hold non-cash assets or real estate property.
Please read the following. 1) You are acknowledging the following regarding the included Grantee Questionnaire: • This inserted Grantee Questionnaire is an accurate and true copy of such previously submitted DASNY Grantee Questionnaire. • The Grantee certifies that there has been no material change in the information provided in the Grantee Questionnaire. EXHIBIT D: Disbursement Terms Village of Croton on Xxxxxx Purchase of a New Fire Boat for the Fire Department Project ID: 25193 Subject to the terms and conditions contained in this Agreement, DASNY shall disburse the Grant to the Grantee as follows: Standard Reimbursement DASNY shall make payment to the Grantee, no more frequently than monthly, based upon Eligible Expenses (as set forth and in accordance with the schedule in Exhibit A) actually incurred by the Grantee, in compliance with Exhibit A and upon presentation to DASNY of the Payment Requisition Forms attached to this Agreement as Exhibit E and its attachments, together with such supporting documentation as DASNY may require in order to clearly demonstrate that Eligible Expenses were actually incurred by the Grantee in connection with the Project described herein. Payment shall be made by reimbursement, subject to the terms and conditions of Sections 4 and 5(a) of this Agreement; by payment on invoice subject to the terms and conditions of Sections 4 and 5(b) of this Agreement; or, for real property acquisition, subject to the terms and conditions of Sections 4 and 5(c) of this Agreement. Supporting documentation acceptable to DASNY must be provided prior to payment, including invoices and proof of payment in a form acceptable to DASNY. If the fronts and backs of canceled checks cannot be obtained from the Grantee’s financial institution, a copy of the front of the check must be provided, along with a copy of a bank statement clearly showing that payment was made by the Grantee to the contractor. DASNY reserves the right to request additional supporting documentation in connection with requests for payment, including the backs of canceled checks, certifications from contractors or vendors, or other documentation to verify that grant funds are properly expended. Please note that quotes, proposals, estimates, purchase orders, and other such documentation do NOT qualify as invoices. The Grantee agrees to provide such documentation to DASNY as may be requested by XXXXX in its sole and absolute discretion to support a requisition for payment, to determine compliance by the Gra...
Please read the following. I understand that any no shows or late cancellations (less than 24 hours notice) will be billed at the rate of $50.00. I also understand that insurances companies will not cover these charges and I am therefore responsible for this payment. • I understand that I am responsible for any charges not covered by my insurance company including deductibles, co-‐pays, and lapses in insurance coverage. Signature of Individual Receiving Services/Legally Responsible Person Date _Jean Xxxxx
Please read the following. All appointments must be in the office. Please be aware that insurance companies do not pay for telephone visits, report writing, frequent/lengthy phone contact, late cancellations and/or no show fees. There may be fees assessed with any and all of these services not covered by insurance. Reports, letters or other paperwork, done while you are not present, may incur a fee. This fee will be based on the amount of time spent on the preparation. In the event of late cancellation or no show, you are responsible for the No Show Fee. The No Show Fee must be paid in full or payment arrangements must be made before another follow up appointment is scheduled. An appointment must be cancelled 48 business hours in advance to avoid the fee. Unavoidable circumstances will be taken into consideration and final determination will be made Xxxxxxx Xxxxxxxxxx MD. In the event that your account gets referred to or placed with our collections agency, you will be fully responsible for all fees assessed with collections and/or any attorney fees or court costs. All copayments, coinsurance, deductibles and past due amounts are due at time of service, if for any reason you are unable to pay at that time, we will require a signed payment arrangement agreement with a credit or debit card information and the dates we may charge the card. A fee for this convenience may be added to each payment made by this method. In the event a payment arrangement is not honored, a fee will be assessed and an alternate payment in full will be required before a follow up appointment will be made. In the event we are not contracted with your insurance company, regardless if it is primary of secondary, you will be responsible for payment. (Example- You have United Healthcare, UHC, as primary and AHCCCS as secondary. Since we are not contracted with AHCCCS, you must pay the copay for UHC. We will not bill an insurance company we are not contracted with.) I have read and understand the above policies. By signing, I acknowledge that I will adhere and agree to all office policies. I am willing to continue with my evaluation or treatment. Printed Name: Signature: Patient Name: Date: Fee Schedule and Codes These are some of the basic codes we may bill for at the cash pay prices, if you do not have insurance or your insurance does not cover mental health you will be responsible for these costs to see Xx Xxxxxxxxxx. All billable codes are not included in this list. If you have any questions, please contact the ...
