FINANCIAL POLICY AND AGREEMENTFinancial Policy and Agreement • March 12th, 2023
Definitions. In this Agreement, “Office” and “Clinic” shall refer to THE PHYSICAL THERAPY CLINIC, INC. dba AXIS PHYSICAL THERAPY located at 26 Office Park Dr. Jacksonville, NC 28546. “Financial Policy” or “Agreement” shall refer to this document.
FINANCIAL POLICY AND AGREEMENT FOR SEEBERGER DERMATOLOGY, LLCFinancial Policy and Agreement • March 21st, 2023
Thank you for choosing us as your healthcare provider. We are committed to providing you with the best possible medical care. Your clear understanding of our practice financial policy is important to our professional relationship. The following information outlines your responsibility related to payment and appointment reservation for professional services. In order to keep healthcare costs to an absolute minimum, we have adopted the following policies.
FINANCIAL POLICY and AGREEMENTFinancial Policy and Agreement • November 29th, 2022
We are pleased and honored that you have selected Spring Creek Dental for your dental needs. Our team is fully committed to delivering the absolute highest quality dental care available and providing you with the tools to maintain your investment in yourself for years to come.
FINANCIAL POLICY AND AGREEMENT CHIROLINA CHIROPRACTICFinancial Policy and Agreement • July 5th, 2017
Definitions. In this Agreement, “Office” and “Clinic” shall refer to Chirolina Chiropractic, P. A. located at 2720 E WT Harris Blvd., Ste. 101“Financial Policy” or “Agreement” shall refer to this document.
— FINANCIAL POLICY AND AGREEMENT —Financial Policy and Agreement • June 18th, 2013
Thank you for choosing us as your health care provider. We are committed to providing you with the best care possible. Please read the following information carefully and completely. Should you have any questions, please contact one of our staff immediately. Your clear understanding of our Financial Policy and Agreement is important to our professional relationship. You must sign and date this form prior to the beginning of care.
FINANCIAL POLICY AND AGREEMENT MICHIANA WELLNESS & LONGEVITY CLINICFinancial Policy and Agreement • April 4th, 2013
Definitions. In this Agreement, “Office”, and “Clinic” shall refer to Michiana Wellness & Longevity Clinic located at 605 W. Edison Road, Mishawaka, IN 46545.
Dental Financial Agreement TemplateFinancial Policy and Agreement • June 17th, 2021
may 10th, 2018 - financial agreement for anesthesia sedation this is a contractual obligation with dr heath snell providing the sedation service and the patient or responsible party accountable for payment on the day of the sedation service'
FINANCIAL POLICY AND AGREEMENTFinancial Policy and Agreement • June 20th, 2017
Our office is committed to providing excellent, affordable medical care. You have the right and responsibility of knowing the cost of your medical treatment. Should you be a cash patient, we may not ask for full payment at the time of service, although you will remain responsible for the full payment of all fees for services provided. If you have health insurance, we bill your insurance company directly, and you will be responsible for co- payments, coinsurance, deductible, and/or non-covered amounts. For your convenience, our office accepts personal checks, credit cards, and cash. Please read the following carefully, as it outlines our financial policy. It is important that insurance patients understand how insurance billing works. Insurance companies require us to break down every component of your office visit into universal, numerical procedure codes, and charge for each code. The insurance companies will arbitrarily change, combine, and disallow procedure codes, and then apply the
FINANCIAL POLICY AND AGREEMENTFinancial Policy and Agreement • January 19th, 2017
Our office is committed to providing excellent, affordable medical care. You have the right and responsibility of knowing the cost of your medical treatment. Should you be a cash patient, we may not ask for full payment at the time of service, although you will remain responsible for the full payment of all fees for services provided. If you have health insurance, we bill your insurance company directly, and you will be responsible for co- payments, coinsurance, deductible, and/or non-covered amounts. For your convenience, our office accepts personal checks, credit cards, and cash. Please read the following carefully, as it outlines our financial policy. It is important that insurance patients understand how insurance billing works. Insurance companies require us to break down every component of your office visit into universal, numerical procedure codes, and charge for each code. The insurance companies will arbitrarily change, combine, and disallow procedure codes, and then apply the
FINANCIAL POLICY AND AGREEMENTFinancial Policy and Agreement • April 22nd, 2014
Parent/Child: The parent/legal guardian accompanying the child is responsible for payment at the time of service including co-payment. The parent/legal guardian with whom the child resides is the person who will be billed for services rendered- which may include: deductibles, co-pays, and any non-covered services provided. The parent/legal guardian is responsible for any balance after insurance has paid.
FINANCIAL POLICY AND AGREEMENTFinancial Policy and Agreement • February 11th, 2015
Definitions. In this Agreement, “Office” and “Clinic” shall refer Total Healing Experience, LLC, doing business as Dr. Melody Y. Matthews, located at 103 Twinridge Lane., North Chesterfield, VA 23235. “Financial Policy” or “Agreement” shall refer to this document.
FINANCIAL POLICY AND AGREEMENTFinancial Policy and Agreement • October 31st, 2017
Few things affect the quality of life as much as the comfort and confidence of comprehensive dental care. At ADANW, we are confident we provide a great value for our patients, providing personalized and high quality and high tech services, not only from Dr. Teasdale, but also from every member of our team. And although we will work with you always to obtain your greatest benefit from your dental insurance, or HSA/FSA accounts, we are not a financial institution and cannot guarantee insurance benefits and insurance payments. We appreciate that people have differing needs in fulfilling their financial obligations, and to help out, we offer the following payment options:
FINANCIAL POLICY AND AGREEMENTFinancial Policy and Agreement • October 13th, 2020
Thank you for choosing us for your dental needs. We are committed to providing you with excellent care and convenient financial arrangements. We feel that an important aspect of your dental treatment is for you to understand our financial/claims processing policies.
Financial Policy and AgreementFinancial Policy and Agreement • August 12th, 2010
The goal of Belmar Smiles is to provide exceptional customer service and excellent dental care with both a professional and personal touch. In order to do so, we want to make certain that our financial policies are clear and understood by our patients.
FINANCIAL POLICY AND AGREEMENTFinancial Policy and Agreement • September 11th, 2021
Thank you for allowing us to be your dental care provider. We are committed to providing the highest quality of dental care to all of our patients. The prompt payment of your treatment fees allows us to continue providing the highest quality of care. In pursuit of these goals, we have established the following financial policies.
— FINANCIAL POLICY AND AGREEMENT —Financial Policy and Agreement • July 29th, 2018
Thank you for choosing us as your health care provider. We are committed to providing you with the best care possible. Please read the following information carefully and completely. Should you have any questions, please contact us immediately. Your clear understanding of our Financial Policy and Agreement is important to our professional relationship. You must sign and date this form prior to the beginning of care.
FINANCIAL POLICY AND AGREEMENTFinancial Policy and Agreement • February 21st, 2007
Health insurance and accident policies are an arrangement between you and your insurance company. As a courtesy to you, we will bill your insurance carrier(s) for you, although please understand that you are responsible for all charges incurred at this facility.
FINANCIAL POLICY AND AGREEMENTFinancial Policy and Agreement • February 25th, 2015
The goal of Alex H. Kang and staff is to make sure that you receive the highest quality dental care and service. One step is to make certain that our financial policies are clear and understood by you.
FINANCIAL POLICY AND AGREEMENT FOR FORENSIC CONSULTATIONSFinancial Policy and Agreement • November 22nd, 2015
The fee for psychological consultation and testimony in forensic cases is $165 per hour, and is charged for all time required to prepare an opinion in the case. Forensic consultations typically involve reviewing documents or evaluations prepared by other professionals, and comparing them to some standard. Activities might include reviewing records; reviewing psychological testing; consultation with your attorney; giving depositions; reviewing relevant literature; report preparation; and court appearance, including travel time. If out-of-town travel is involved, expenses will be added. Please note that the fees charged are for professional time and expertise, and do not influence professional judgment. Copying of file documents is done at 50 cents per page.
FINANCIAL POLICY AND AGREEMENTFinancial Policy and Agreement • February 7th, 2019
Incorporation of Assignment of Terms and Definitions. In this Agreement, “Office” shall refer to Allendale Bone & Joint Clinic, dba Allendale Chiropractic Clinic. I have reviewed the Office’s Assignment form titled in short as “Assignment” or “Assignment / Lien.” The terms and definitions contained in the Assignment are incorporated herein by reference.
FINANCIAL POLICY AND AGREEMENTFinancial Policy and Agreement • March 9th, 2022
We invite you to discuss frankly with us any questions regarding our services. The best health services are based on a friendly, mutual understanding between provider and client.
FINANCIAL POLICY AND AGREEMENTFinancial Policy and Agreement • April 21st, 2020
Welcome to Affiliated Wellness Group, LLC and thank you for choosing us as your health care provider. We look forward to providing you quality treatment and professional service. Please understand that payment of your bill is considered a vital part of your treatment. The following is a statement of our Financial Policy, which we require you to read and sign prior to your treatment.
FINANCIAL POLICY AND AGREEMENTFinancial Policy and Agreement • July 22nd, 2022
At Wisconsin River Orthopaedic Institute we are committed to providing you with the best possible care and are pleased to discuss our professional fees with you. Our fees for services are based on the level of professional skill required, the severity and complexity of the injury or illness, as well as the time spent treating you. The patient or responsible party is responsible for seeing that the entire bill is paid in full.
FINANCIAL POLICY AND AGREEMENTFinancial Policy and Agreement • July 19th, 2022
We invite you to discuss frankly with us any questions regarding our services. The best health services are based on a friendly, mutual understanding between provider and client.
— FINANCIAL POLICY AND AGREEMENT —Financial Policy and Agreement • April 14th, 2022
Thank you for choosing us as your health care provider. We are committed to providing you with the best care possible. Please read the following information carefully and completely. Should you have any questions, please contact us immediately. Your clear understanding of our Financial Policy and Agreement is important to our professional relationship. You must sign and date this form prior to the beginning of care.
FINANCIAL POLICY AND AGREEMENT TO PAY FOR SERVICESFinancial Policy and Agreement • March 7th, 2019
Reed Psychological Services, PLLC is committed to providing caring and professional mental health care to all of our clients. As part of the delivery of mental health services, we have established a financial policy that provides payment policies and options to all consumers. The financial policy of the clinic is designed to clarify the payment policies as determined by the management of the clinic. Payment for services is considered part of your treatment and we want to ensure that you understand your financial rights and responsibilities related to your care at RPS. Understanding and completing this form will allow you to get the most out of your care and help us to best serve you.
FINANCIAL POLICY AND AGREEMENTFinancial Policy and Agreement • April 4th, 2018
Our office is committed to providing excellent, affordable medical care. You have the right and responsibility of knowing the cost of your medical treatment. Should you be a cash patient, we may not ask for full payment at the time of service, although you will remain responsible for the full payment of all fees for services provided. If you have health insurance, we bill your insurance company directly, and you will be responsible for co- payments, coinsurance, deductible, and/or non-covered amounts. For your convenience, our office accepts personal checks, credit cards, and cash. Please read the following carefully, as it outlines our financial policy. It is important that insurance patients understand how insurance billing works. Insurance companies require us to break down every component of your office visit into universal, numerical procedure codes, and charge for each code. The insurance companies will arbitrarily change, combine, and disallow procedure codes, and then apply the
FINANCIAL POLICY AND AGREEMENTFinancial Policy and Agreement • September 17th, 2020
We invite you to discuss frankly with us any questions regarding our services. The best health services are based on a friendly, mutual understanding between provider and client.
FINANCIAL POLICY AND AGREEMENTFinancial Policy and Agreement • September 3rd, 2019
The goal of South University Dental Associates is to make sure you receive the highest quality dental care and services. One step is to make certain that our financial policy is clear and understood by you.
FINANCIAL POLICY AND AGREEMENTFinancial Policy and Agreement • September 15th, 2015
Incorporation of Assignment Terms and Definitions. In this Agreement, “Office” and “Clinic” shall refer to ADVANCED CHIROPRACT IC & SPORTS CARE. I have reviewed the Office’s Assignment form titled in short as “Assignment” or Assignment/Lien”. The terms and definition contained in the Assignment are incorporated herein by reference.
FINANCIAL POLICY AND AGREEMENTFinancial Policy and Agreement • January 3rd, 2023
We invite you to discuss frankly with us any questions regarding our services. The best health services are based on a friendly, mutual understanding between provider and client.
