Financial Agreement and Assignment of Benefits Sample Contracts
Financial Agreement and Assignment of BenefitsFinancial Agreement and Assignment of Benefits • October 22nd, 2018
First Name Middle Name Last NameFinancial Agreement and Assignment of Benefits • October 26th, 2017
Edward J. Wladis, MD/Michael I. Rothschild/Dale R. Meyer, MD/Charlotte L. Marous, MD Financial Agreement and Assignment of BenefitsFinancial Agreement and Assignment of Benefits • January 4th, 2023
FINANCIAL AGREEMENT AND ASSIGNMENT OF BENEFITSFinancial Agreement and Assignment of Benefits • February 19th, 2025
Dental Surgeons and Associates is a privately-owned dental facility that provides medical services on a fee-for-service basis. DSA relies solely on insurance reimbursement and patient payment(s) for services rendered in good faith. DSA receives no federal, state, or other third- party funding; as such, DSA does not have provision for providing on-going indigent care. The following Financial Agreement is developed in accordance with Office of Inspector General (OIG) guidelines as well as all applicable State and Federal reimbursement guidelines. For the convenience of our patients, DSA participates with most Dental insurance companies. DSA will submit claims for all medically necessary services to your insurance company. Please note that payment is ultimately due from you if your insurance company denies payment for any service(s); i.e. termination of coverage, coordination of benefits, non-payment of premium, non-participating status, etc. If we do not participate with your dental plan
FINANCIAL AGREEMENT AND ASSIGNMENT OF BENEFITSFinancial Agreement and Assignment of Benefits • June 1st, 2022
Kelly Eye Center (KEC) are privately-owned medical facilities that provide medical services on a fee-for-service basis. KEC relies solely on insurance reimbursement and patient payment(s) for services rendered in good faith. KEC receives no federal, state or other third-party funding; as such, KEC does not have provision for providing on-going indigent care. The following Financial Agreement is developed in accordance with Office of Inspector General (OIG) guidelines as well as all applicable State and Federal reimbursement guidelines.
First Name Middle Name Last NameFinancial Agreement and Assignment of Benefits • October 26th, 2017
FINANCIAL AGREEMENT AND ASSIGNMENT OF BENEFITSFinancial Agreement and Assignment of Benefits • August 30th, 2021
Retina Health Center, P.L. (RHC) are privately-owned medical facilities that provide medical services on a fee-for-service basis. RHC relies solely on insurance reimbursement and patient payment(s) for services rendered in good faith. RHC receives no federal, state or other third-party funding; as such, RHC does not have provision for providing on-going indigent care. The following Financial Agreement is developed in accordance with Office of Inspector General (OIG) guidelines as well as all applicable State and Federal reimbursement guidelines.
FINANCIAL AGREEMENT AND ASSIGNMENT OF BENEFITSFinancial Agreement and Assignment of Benefits • March 31st, 2022
Southwest Florida Eye Care, LLC. (SFEC) are privately-owned medical facilities that provide medical services on a fee-for-service basis. SFEC relies solely on insurance reimbursement and patient payment(s) for services rendered in good faith. SFEC receives no federal, state or other third-party funding; as such, SFEC does not have provision for providing on-going indigent care. The following Financial Agreement is developed in accordance with Office of Inspector General (OIG) guidelines as well as all applicable State and Federal reimbursement guidelines.
First Name Middle Name Last NameFinancial Agreement and Assignment of Benefits • October 26th, 2017