Thank you for choosing us as your health care provider. In order to serve you better, we require that all patients read and sign our financial policy. It is your responsibility to understand whether your provider is In-Network to maximize your benefits. We will be glad to assist you with any questions you may have.
  1. Your insurance card must be presented at each visit. It is your responsibility to provide us with ALL the correct information to ensure proper billing to your insurance company. We will require a patient information sheet to be filled out once a year.
  2. We will collect your co-payment, deductible, coinsurance, or charges for noncovered services at the time of your visit. If you have a balance from a previous visit, we will also ask for that payment. We accept cash, checks and all major credit cards. Returned checks or stop payments will incur a service charge, currently $30.00.
  3. Surgery and Maternity patients: We will verify your benefits with your insurance company and inform you of any deposit due such as unmet deductible or coinsurance. Surgery deposits are due at least 5 days prior to surgery. Maternity patients will be given a payment plan to be Paid in Full before the seventh month of pregnancy.
  4. Discounts such as professional courtesy, filing insurance only, waiving copayment, coinsurance or deductible are expressly forbidden by the managed care contracts our office has signed.
  5. Medicare Patients: As a participating provider, we will file your Medicare claim for you. If you have a supplemental policy, we will also bill that for you. Each year you will be expected to pay the allowed amount of your charges until your Medicare annual deductible has been met. You are responsible for any noncovered services.
  6. Self-Pay Patients: Without medical coverage, payment is expected at the time of service. If you are unable to pay in full, you must contact our billing office prior to your appointment to make payment arrangements.
  7. Disability and health forms are completed for a fee of $20.00 per form and must be paid when presented. We will require at least 14 business days to prepare your forms.
  8. Any unpaid accounts are reported to the credit bureau after 90 days. If reported, the fact that you received treatment at our office may become a matter of public record.
    9. I certify that the insurance information I have provided is correct. I agree to pay in full for services upon notification that these charges have not been paid and are my responsibility. Any patient balance unpaid after ninety (90) days will be reported to the credit bureau and the patient will be released from the practice for nonpayment. The unpaid balance will be referred to a collection agency. We reserve the right to change our financial policy at any time.