Receipt of Privacy Notice
Cancellation and Fees
Please read carefully. You will be asked to complete this form at the office. You are acknowledging that you have read and, most importantly, understand these policies. We require that you fully initial and sign the form at our office before we provide you with any services.
Patient Consent and Acknowledgement of Receipt of Privacy Notice
Insurance or Address Changes
Consent to Treatment and Financial Responsibility
Consent for Labwork/Ancillary Services
Cancellation and Payment Policy
Self Pay Patients
Full payment is due at the time of service. We accept cash, Visa, MasterCard, Discover, and American Express.
We highly recommend that you READ YOUR INSURANCE BOOKLET or a copy of the contract your policy falls under to determine your benefits. Should your insurance carrier require you to use specific ancillary facilities (labs, x-rays, etc), inform your nurse. It is imperative we receive this information at the time of service. Failure to do so may result in charges to you which your insurance may not cover. Your insurance is an agreement between you and your insurance company. You are responsible for timely payment of your account.
If you have an insurance plan that we are not contracted with, full payment is due. We will gladly give you an itemized statement so that you may file the claim with your insurance company for reimbursement.
Filing insurance claims is a service we provide free of charge but in no way relieves you from the responsibility of your bill. It is your responsibility to know your insurance policy coverage and benefits. It is also your responsibility to let us know of any insurance changes in a timely manner.
Checks returned for Non-Sufficient Funds will be charged a fee of $25.00. We do not re-deposit an NSF check a second time. Balances must be handled by cash, credit card or money order.
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