PATIENT FINANCIAL AGREEMENT & ACKNOWLEDGEMENT OF OFFICE POLICIESPatient Financial Agreement • May 28th, 2020
Ophthalmology Associates believes that part of good health care practice is to establish and communicate an office and financial policy to our patients. We are dedicated to providing the best possible care for you, and we want you to have a full understanding of our policies.
Patient Financial AgreementPatient Financial Agreement • October 16th, 2020
Please read the following information closely. If you have any questions, please ask. We want to ensure that you completely understand our financial policies.
Patient Financial AgreementPatient Financial Agreement • February 16th, 2021
Patient Financial AgreementPatient Financial Agreement • September 20th, 2021
(Please fully read, sign on back, and return to the receptionist. We will be happy to furnish you with another copy for your records. It is also available on the website.)
Patient Financial AgreementPatient Financial Agreement • December 28th, 2018
Patient Financial AgreementPatient Financial Agreement • November 22nd, 2020
PATIENT FINANCIAL AGREEMENT & ACKNOWLEDGEMENT OF OFFICE POLICIESPatient Financial Agreement • January 26th, 2022
Thank you for choosing us as your health care provider. We are committed to providing quality care and service to all of our patients. United Physician Group (“UPG”) believes that part of good health care practice is to establish and communicate an office and financial policy to our patients proactively and effectively. We are dedicated to providing the best possible care for you, and we want you to have a full understanding of our policies.
EDGEFIELD MEDICAL CENTERPatient Financial Agreement • March 2nd, 2021
EDGEFIELD MEDICAL CENTERPatient Financial Agreement • October 6th, 2020
PATIENT FINANCIAL AGREEMENTPatient Financial Agreement • April 14th, 2020
Arizona Eye Consultants is committed to serving our patients with professionalism and caring. We ask the same from you. This includes:
PATIENT FINANCIAL AGREEMENTPatient Financial Agreement • November 28th, 2016
Co-payments are due at the time of service. If you are unable to remit your co-payment amount, the office reserves the right to reschedule your appointment for another day/time that is convenient for you. If you wish to be seen at your regularly scheduled appointment the practice reserves the right to bill an additional $20.00 fee if the copay is not remitted by the end of the business day.
PATIENT FINANCIAL AGREEMENTPatient Financial Agreement • March 7th, 2011
Patient Financial AgreementPatient Financial Agreement • August 18th, 2021
Please read the below terms and conditions in this Patient Financial Agreement (“Agreement”) carefully as it is our intent with this policy to outline patient and practice financial responsibilities and obligations fairly and clearly. You will be asked to sign this document. This Agreement will remain in full force and effect unless modified by Physician’s for Women’s Health, LLC, its successors, and assigns.
PATIENT FINANCIAL AGREEMENTPatient Financial Agreement • December 31st, 2014
We strive to maintain a strong physician-patient relationship. Sharing our Financial Policy in advance allows for a good flow of communication and enables us to achieve our goal. If you have any questions, do not hesitate to ask a member of our staff.
Patient Financial AgreementPatient Financial Agreement • October 16th, 2020
Please read the following information closely. If you have any questions, please ask. We want to ensure that you completely understand our financial policies.
Patient Financial AgreementPatient Financial Agreement • November 2nd, 2020
(Please fully read, sign on back, and return to the receptionist. We will be happy to furnish you with another copy for your records. It is also available on the website.)
Patient Financial AgreementPatient Financial Agreement • September 22nd, 2020
We would like to take this opportunity to Thank-you for choosing Pediatric Neurologists of Palm Beach to provide your child’s neurological care.
ContractPatient Financial Agreement • October 17th, 2021
Patient Financial Agreement Thank you for choosing PRIME MD OF NAPLES as your health care 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 The patient is expected to present an insurance card at each visit. All co-payments 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 mos
PATIENT FINANCIAL AGREEMENTPatient Financial Agreement • March 23rd, 2017
Our Mission is to improve the health of our community by providing high quality, caring, culturally appropriate health care that addresses the needs of people regardless of their ability to pay.
David E Vitunac, D.M.D.Patient Financial Agreement • August 16th, 2021
This agreement is to inform you of your financial obligation to our practice. We are committed to providing you with the highest quality dental care using only the best material and technology available in the market today. We are also committed to providing you with up-to-date information and educational tools so you may fully participate in maintaining optimum oral health.
Client/Patient Financial Agreement with Waterstone Counseling CentersPatient Financial Agreement • December 30th, 2021
Waterstone Counseling Centers, LLC is committed to serving our patients with professionalism, care, and concern. We ensure commitment to your treatment, but also expect commitment from our patients including financial responsibility. This includes providing current and accurate insurance information and making copay payments and/or paying the current balance owed at the time of each in-person or telehealth session. Deductible and co-insurance balances will be determined when claims are processed and the front desk will notify patients of any balance due. During the establishment of new services, patients will be made aware of their financial responsibility based on their insurance information or self-pay status. The terms of their private insurance or self-pay status will be documented, given to patient, and saved in patient chart for reference.
Patient Financial AgreementPatient Financial Agreement • October 12th, 2021
This document is a breakdown of Health Travel, Immunizations, and Physicals financial policies and an explanation of potential charges you could owe related to services at our office. Actual amounts vary depending on the type of service provided and your health insurance coverage at the time of service. This list is not comprehensive and may be updated without prior notice.
PATIENT FINANCIAL AGREEMENT FOR THE OFFICE OFPatient Financial Agreement • May 24th, 2010
Mint Dental Patient Financial AgreementPatient Financial Agreement • January 21st, 2020
We will gladly verify your dental benefits and process your primary and secondary claims with the following agreement:
PATIENT FINANCIAL AGREEMENT AND OFFICE POLICIESPatient Financial Agreement • May 31st, 2021
PATIENT FINANCIAL AGREEMENTPatient Financial Agreement • September 12th, 2013
Statement: It is our responsibility and primary goal to provide quality oral health care for our patients with the best possible treatment in a safe environment. We use high quality supplies and materials. In the interest of good practice we have established a financial policy. An effective financial policy enables the provider and the patient to avoid misunderstandings. Often the goals of Insurance companies are to treat patients in the least expensive manner, and not necessarily the most effective and customized way for an individual patient needs. We provide our patients with the finest treatment available and base our treatment recommendations on what would be best for you or your child rather than what your insurance company will not pay.
Patient Financial AgreementPatient Financial Agreement • May 28th, 2004
PATIENT FINANCIAL AGREEMENTPatient Financial Agreement • November 3rd, 2020
Welcome to Piedmont Internal Medicine. We are dedicated to making sure that our patients are provided with exceptional medical care. We strongly encourage each patient to contact their insurance company to confirm their doctor is a participating provider in their plan.
Patient Financial AgreementPatient Financial Agreement • June 2nd, 2016
We are dedicated to providing you with the best possible care and consider your understanding of this financial agreement an essential part of the services you receive at Monarch Healthcare.
JUBILEE FAMILY DENTISTRY - PATIENT FINANCIAL AGREEMENTPatient Financial Agreement • October 9th, 2019
Thank you for choosing us as your dental care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered part of your treatment. Since our practice is also a business with obligations that must be met, we ask that all patients pay for their treatment on the day of each visit to our office. The following is a statement of our financial policy which we require that you read and sign prior to any treatment.
Patient Financial AgreementPatient Financial Agreement • May 12th, 2017
Thank you for allowing us the opportunity to care for your dental needs. We are excited to partner with you to improve and maintain your oral health.
PATIENT FINANCIAL AGREEMENTPatient Financial Agreement • October 26th, 2016
We strive to maintain a strong physician-patient relationship. Sharing our Financial Policy in advance allows for a good flow of communication and enables us to achieve our goal. If you have any questions, do not hesitate to ask a member of our staff.
Patient Financial AgreementPatient Financial Agreement • June 27th, 2018
• Accepted payment types: cash, check, all major credit cards, care credit 5% discount available with cash or check payments on restorative treatment only, when paid in full at time of service (offer not valid with debit/credit payment, hygiene services, or with insurance).
PATIENT FINANCIAL AGREEMENTPatient Financial Agreement • September 11th, 2017
Thank you for choosing us for your GI care. We are committed to providing you with quality care. We ask all patients to review and sign this policy. A copy will be provided to each patient upon request.
Patient Financial AgreementPatient Financial Agreement • February 20th, 2012
