Insurance: Our office is happy to help you with submitting your insurance claim. However, you will need to provide our office with the necessary information concerning your insurance coverage to allow correct filing. Your insurance company will pay only what it considers the usual and customary fee for each service. Therefore, you may be responsible for the unpaid portion.
Payments: Payment is expected at the time of service, including fees not covered by your insurance plan. Our office accepts Visa, Mastercard, Discover, American Express, checks and cash. We also offer CareCredit, a medical payment plan designed to pay for healthcare not covered by insurance.
Cancellations: If you are unable to keep your appointment that you have scheduled with us, please notify us at least 24 hours in advance. We try hard to accommodate all of our patients and we understand there are emergencies that do arise. We would be happy to reschedule your appointment at a more convenient time if necessary. If 24 hour notice is not given, you will be charged a missed appointment fee. Our office is closed on weekends, therefore any cancellations for Monday appointments must be made by Friday.
Past Due Accounts: Overdue accounts will be referred to Congress Collection Agency if more than 90 days past due. If your account goes to collections, you agree to be responsible for all fees involved in the collection process.
Returned Checks: For checks returned to us, as unpaid by your bank, we will charge a $35.00 fee.
Please sign this form stating that you have read, understand, and will comply with the information contained within this document.
I have read and understand the office policies stated above.