Private Pay Agreement Example FormPrivate Pay Agreement • October 19th, 2006
as private pay patient for the period of , and I will be responsible for paying for any services I receive. The provider will not file a claim to Medicaid for services provided to me.
PRIVATE PAY AGREEMENTPrivate Pay Agreement • January 22nd, 2021
Private Pay AgreementPrivate Pay Agreement • October 16th, 2014
Note: All Private pay patient will need to pay a deposit prior to being seen. $200 for new patients, $100 for established patients)Private Pay Agreement • October 14th, 2021
□ Patient does not have health insurance coverage – Payment due in full at time of service. Midland Primary Care offers a 25% discount to qualifying patients for payment at time of service.
PRIVATE PAY AGREEMENTPrivate Pay Agreement • February 10th, 2019
I, (print name of person responsible for payment), by signing this agreement, indicate that I understand that my or my child’s treatment with Dr. Michelle Spader beginning (date) will not be covered by insurance because (please initial one below):
Private Pay AgreementPrivate Pay Agreement • November 17th, 2014
Private Pay AgreementPrivate Pay Agreement • August 1st, 2013
PRIVATE PAY AGREEMENTPrivate Pay Agreement • February 15th, 2017
Payment for one week is due prior to the start of Topical Oxygen Therapy. Subsequent payments should be received in Provider’s billing office within fifteen (15) days of billing invoice date. If payment is not received within fifteen (15) days after notification, Topical Oxygen Therapy will be stopped.
Private Pay AgreementPrivate Pay Agreement • January 29th, 2020
Private Pay AgreementPrivate Pay Agreement • November 19th, 2018
Self-‐Pay / Private Pay AgreementPrivate Pay Agreement • August 4th, 2020
This agreement is set forth to accommodate patients without insurance coverage or for patients that are covered by insurance that Geneva Eye Clinic is not currently contracted with. Self-‐Pay patients will receive a discount on services rendered.
PRIVATE PAY AGREEMENT FOR THERAPY SERVICESPrivate Pay Agreement • June 2nd, 2020
PRIVATE PAY AGREEMENTPrivate Pay Agreement • November 15th, 2011
Private Pay Agreement/Patient Service AgreementPrivate Pay Agreement • June 6th, 2020
DO NOT USE OUR APPLICATION TO SEEK MEDICAL SERVICES FOR SOMEONE WHO IS UNCONSCIOUS, NOT BREATHING OR GASPING FOR AIR, HAVING CHEST PAIN, UNCONTROLLABLY BLEEDING, OR ANY OTHER SYMPTOMS THAT REQUIRE IMMEDIATE OR EMERGENT MEDICAL ATTENTION. CALL 911 OR GO TO THE NEAREST EMERGENCY ROOM (ER) IMMEDIATELY IF YOU HAVE AN EMERGENCY MEDICAL NEED.
MEDICAID PRIVATE PAY AGREEMENTPrivate Pay Agreement • June 2nd, 2022
