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Financial Policy & Agreement Form

Denali Medical Center is dedicated to professionalism and caring for our patients. We hope to be as up front and consistent as possible in explaining your obligations in our partnership to your health.

Please read, check each box and sign where indicated – this document describes your financial responsibilities. This is a legally binding contract between Denali Medical Center and the patient.

I agree to be financially responsible for payment of all services I receive at Denali Medical Center. Cash, checks, health savings accounts, credit cards or financing are acceptable forms of payment for the service provided.

I understand that the services provided at Denali Medical Center are not recognized or covered by most insurance companies and will not be billed through insurance.

I understand that Denali Medical Center’s package opportunities (such as RenuO2 Regeneration Package) have a limited time span available to use the treatments. This is intended to benefit the patient, since those who have followed the treatment schedules have experienced the highest success rates.

I understand that the package pricing offered at Denali Medical Center applies discounted rates. Any credits or refunds will be calculated from full valued price.

I have provided Denali Medical Center my current address and other contact information. I understand that if I fail to pay the balance on my account, this may result in Denali Medical Center pursuing any collection means possible.

If my account becomes delinquent, it may be forwarded to an outside collection agency without notice. If this happens, I will be responsible for all costs of collection, including but not limited to interest, rebilling fees, court costs, attorney fees, and collection agency costs.

I understand Denali Medical Center’s financial policies and I accept responsibility for the payment of any fees associated with my care.

I understand that I will be responsible for any missed appointments or any canceled appointments in which a 24 hour notice was not given. There will be a fee of $50.00 for any missed office procedures.

I understand there will be a $25.00 fee for all returned checks.

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July 9, 2019 8:34 am MDT

Financial Policy & Agreement Form Uploaded by Denali Medical - accounts@denalimed.com IP 107.191.1.125

July 10, 2019 8:40 pm MDT

Cindy Meldrum - cmeldrum@denalimed.com added by Lisa Strauss - accounts@denalimed.com as a CC'd Recipient Ip: 107.191.1.119