Patient benefits will be verified with insurance prior to your office visit and co-pay will be collected at the time of service by cash or credit card (NO CHECKS).
ALL CO-PAYS ARE DUE AT THE TIME OF SERVICE.
Deductibles will be collected in full at the time of follow up appointment, after insurance has processed claims.
Patients with outstanding balances will be requested to pay the balance in full, prior to their appointment, by cash or credit card (NO CHECKS).
If amount remains unpaid after 90 days, the account will be referred to collection agency and an additional 10% fee will be applied to cover collection fee.
NO SHOW/CANCELATION POLICY:
NO SHOW/CANCELATION POLICY:
Any cancellation for an appointment without a 24-hour notice, depending on the circumstances of course, there will be charge a $25, that will have to be collected at the time of your next visit by cash or credit card.
There will be a $25 charge for a NO SHOW, that will be collected at time of your next visit.
If you do not show up or cancel appointments without 24 hour notice 3 times, we will not be able to schedule any further appointments with our practice.
NOTICE TO ALL HMO PATIENTS
NOTICE TO ALL HMO PATIENTS
It is the patient’s responsibility to obtain & present valid updated referrals for each office visit.
If you do not have a valid referral to cover services in our office, your appointment will be cancelled. As your insurance will not cover any of our services without a valid referral, any service without a valid referral, will become patient responsibility.
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PATIENT RESPONSIBILITY
PATIENT RESPONSIBILITY
I understand that while my insurance may confirm my benefits, confirmation of benefits is not a guarantee of payment and I am responsible for any unpaid balance.
I understand that it is my responsibility to know if my insurance has any deductible, copay, coinsurance, out of network, usual and customary limit, prior authorization requirements, or any other type of benefit limitation for the services I receive.
I agree to inform the office of any changes in my insurance coverage. If my insurance is terminated at time of service, I agree I am financially responsible for the balance in full.
If our office has not been provided the accurate secondary insurance information, it will not be billed. It will become my financial responsibility to pay this balance and then file a claim with my secondary insurance for reimbursement.
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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
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