Welcome to our office! We are committed to your treatment being successful. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our Financial Policy which we require you read and sign prior to any treatment.
All patients must complete our information and insurance requirements before seeing the PROVIDER. Please note:
FULL PAYMENT IS DUE AT TIME OF SERVICE.
We accept: Health Insurance, Cash, Checks, Visa, Master Card, Discover, & American Express
We do not accept any other form of payment.
If you do not have insurance:
Payment is due at the time of service. We provide a generous cash discount for our clients.
Canceled and Missed Appointments:
We need your help. Please DO NOT be a No Show. What is a No Show? An appointment in which the patient did not appear for care and did not cancel the appointment at least one day before hand.
Why is this important?
It helps to ensure all patients are provided care in a timely manner.
It helps to increase timely access to our clinic.
It helps us reduce cost.
When booking an appointment with us, we will require a $30 reservation fee from you to confirm your appointment. This reservation fee will be credited towards your care at your appointment. If your visit involves zero copay or coinsurance, the reservation fee will be refunded to you. The reservation fee is $0 if you come to your appointment or you cancel with at least 24 hours of notice. If you miss the appointment or do not cancel within 24 hours of your appointment, the reservation fee will convert to an administration fee.
Regarding Health Insurance:
We may accept assignment of insurance benefits upon verification of eligible benefits. At the time of service your co-payments and/or deductibles are due. The balance of your account is your responsibility whether your insurance company pays or not.
Your insurance policy is a contract between you and your insurance company. We are not a party to that contract.
If your insurance company has not paid your account in full within 60 days, the balance will be automatically billed to you.
We aim to provide our patients with the best possible diagnosis and treatment. However, the health insurance plan under which you have certain benefits includes strict criteria for coverage of medical, hospital, and other services.
It is not always possible to anticipate when services will be covered or when services will be denied. Therefore, it is not safe to assume that your plan covers "everything". We recommend that you verify the benefits covered in your individual policy in order to prevent unhappy surprises.
Thank you for understanding our Financial Policy. Please let us know if you have questions or concerns.
Late Payment of Balances
Payments are due at time of services rendered. All outstanding balances are due in full by the 30th day after treatment. If payment is not received, in full, by the 30th day after treatment, there will be a finance charge equivalent to 18% annual percentage rate, compounded monthly, added to your account. Payments not received in full may be subject to additional late charges, collection costs and legal (attorney's) fees. Returned or insufficient fund credit/debit transactions are considered late payments and are subject to a $35 charge.
I have read the financial policy and responsibility statement above. I understand the above policy and agree to it.