MEMBER/PATIENT RESPONSIBILITY AGREEMENTPatient Responsibility Agreement • May 22nd, 2012
Participating health care professionals/facilities ("Providers") are prohibited from charging members for any service, product or upgrade (collectively, "Service") that is deemed not medically necessary, unless the member specifically requests such Service and agrees in writing to be financially responsible for It. This waiver form shall be used to document the Member's agreement to be responsible for such Services, To be effective and valid, this document must be executed prior to the delivery of any non-medically necessary Service.
PATIENT RESPONSIBILITY AGREEMENT FOR CONTROLLED SUBTANCE MEDICATIONSPatient Responsibility Agreement • May 4th, 2022
Controlled substance medications (i.e., narcotics, tranquilizers and barbituates) are very useful, but have a high potential for misuse. Therefore, they are closely controlled by local, state, and federal governments. Narcotics do not treat the underlying painful condition; they simply act in the brain to decrease the perception of pain. Our physicians are dedicated to restoring function us an efficient and functional manner. Narcotic medications may or may not be an appropriate way to achieve this.
Patient Responsibility Agreement Over 18 HIPAA Release and ConsentPatient Responsibility Agreement • March 7th, 2018
PATIENT RESPONSIBILITY AGREEMENT FOR CONTROLLED SUBTANCE MEDICATIONSPatient Responsibility Agreement • February 7th, 2023
Controlled substance medications (i.e., narcotics, tranquilizers and barbituates) are very useful, but have a high potential for misuse. Therefore, they are closely controlled by local, state, and federal governments. Narcotics do not treat the underlying painful condition; they simply act in the brain to decrease the perception of pain. Our physicians are dedicated to restoring function as an efficient and functional manner. Narcotic medications may or may not be an appropriate way to achieve this.
PATIENT RESPONSIBILITY AGREEMENTPatient Responsibility Agreement • July 11th, 2016
This is to inform you that your insurance carrier may not cover procedures or diagnostic tests that your doctors consider necessary for the proper treatment of your medical condition. We agree to file the claims for you and assist in any appeal process necessary.
PATIENT RESPONSIBILITY AGREEMENT FOR CONTROLLED SUBSTANCE MEDICATIONSPatient Responsibility Agreement • January 29th, 2018
Controlled substance medications (i.e., narcotics, tranquilizers and barbituates) are very useful, but have a high potential for misuse. Therefore, they are closely controlled by local, state, and federal governments. Narcotics do not treat the underlying painful condition; they simply act in the brain to decrease the perception of pain. Our physicians are dedicated to restoring functional use in an efficient and functional manner. Narcotic medications may or may not be an appropriate way to achieve this.
Patient Responsibility AgreementPatient Responsibility Agreement • October 26th, 2017
MEMBER/PATIENT RESPONSIBILITY AGREEMENTPatient Responsibility Agreement • May 22nd, 2012
Participating health care professionals/facilities ("Providers") are prohibited from charging members for any service, product or upgrade (collectively, "Service") that is deemed not medically necessary, unless the member specifically requests such Service and agrees in writing to be financially responsible for It. This waiver form shall be used to document the Member's agreement to be responsible for such Services, To be effective and valid, this document must be executed prior to the delivery of any non-medically necessary Service.
Patient Responsibility Agreement for Controlled Substances PrescriptionsPatient Responsibility Agreement • January 17th, 2019
Controlled substance medications (ie narcotics, tranquilizers, and barbiturates) are very useful but have a high potential for misuse and are, therefore, closely controlled and monitored by the local, and state, as well as the federal government. The conditions outlined here are designed to keep both patient and physician within the bounds of applicable laws. By accepting a prescription for a controlled substance, I understand and agree to the following:
PATIENT RESPONSIBILITY AGREEMENTPatient Responsibility Agreement • July 11th, 2016
This is to inform you that your insurance carrier may not cover procedures or diagnostic tests that your doctors consider necessary for the proper treatment of your medical condition. We agree to file the claims for you and assist in any appeal process necessary.
PATIENT RESPONSIBILITY AGREEMENT and INSURANCE POLICYPatient Responsibility Agreement • February 19th, 2019
We would like to take this opportunity to Welcome you to our practice and assure you that we will do our utmost to provide you or your child with the best possible care. The following is a statement of our Financial Policy, which we require that you read, agree to and sign prior to you/your child’s first visit.
Patient Responsibility AgreementPatient Responsibility Agreement • September 7th, 2018
We bill all insurance payers although we may not be contracted with all insurance companies. If we are a network provider for your insurance company, they will pay for our services at the negotiated rate and we will apply the appropriate payments and adjustments to your account. It is your responsibility to pay deductibles, copayments or coinsurances. All out of network charges will be negotiated as discussed per this agreement.
PATIENT RESPONSIBILITY AGREEMENTPatient Responsibility Agreement • September 20th, 2016
PATIENT RESPONSIBILITY AGREEMENTPatient Responsibility Agreement • July 11th, 2016
This is to inform you that your insurance carrier may not cover procedures or diagnostic tests that your doctors consider necessary for the proper treatment of your medical condition. We agree to file the claims for you and assist in any appeal process necessary.
PATIENT RESPONSIBILITY AGREEMENTPatient Responsibility Agreement • December 3rd, 2015
PATIENT RESPONSIBILITY AGREEMENT and INSURANCE POLICYPatient Responsibility Agreement • January 6th, 2017
We would like to take this opportunity to welcome you to our practice and assure you that we will do our utmost to provide you with the best possible care. Patients (parents) are requested to pay for services the day they are performed. Cash, check and credit cards are all accepted forms of payment. Diagnostics, like x-rays, and treatment are rendered based on standards of care adopted by the doctor. These may conflict with insurance frequencies for coverage or patient’s requested treatment desires. Ultimately, after discussion, treatment may be required to continue care. It is preferred that children 6 years and under, or those deemed by the doctor to benefit, are seen in the morning. Parents may accompany them into the treatment areas. In the afternoon, our office is attempting to set up for those children who have graduated to independent treatment with the doctor and clinicians.
PATIENT RESPONSIBILITY AGREEMENTPatient Responsibility Agreement • December 12th, 2016
PATIENT RESPONSIBILITY AGREEMENTPatient Responsibility Agreement • July 11th, 2016
This is to inform you that your insurance carrier may not cover procedures or diagnostic tests that your doctors consider necessary for the proper treatment of your medical condition. We agree to file the claims for you and assist in any appeal process necessary.
Patient Responsibility Agreement for Controlled Drug PrescriptionsPatient Responsibility Agreement • February 16th, 2022
Controlled substance medications (i.e. narcotics, tranquillizers and barbiturates) are very useful, but have a high potential for misuse and are, therefore, closely controlled by local, state and federal governments. They are intended to relieve pain, thus improving function and/or ability to work. Because my physician is prescribing controlled substance medications to help manage my pain, I agree to the following conditions:
