1. Payment is due at the time of service unless arrangements
have been made in advance by your carrier. We accept Visa and MasterCard.
2. Keep in mind that your insurance policy is basically
a contract between you and your insurance company. As a service
to you, we will file your insurance claim if you assign the benefits
to the doctor—in other words, if you agree to have your insurance
company pay the doctor directly. If your insurance company does
not pay the practice within a reasonable period, we will have to
look to you for payment. If we later receive a check from your insurer,
we will refund any overpayment to you.
3. We have made prior arrangements with many insurance
companies and other health plans to accept an assignment of benefits.
We will bill them, and you are required to pay a copayment at the
time of your visit.
4. If you are insured by a plan that we do not have a prior
arrangement with, we will prepare and send the claim for you on
an unassigned basis. This means the insurer will send the payment
directly to you. Therefore, our charges for your care are due at
the time of service.
5. Not all insurance plans cover all services. In the event
your insurance plan determines a service to be “not covered,”
you will be responsible for the complete charge. Payment is due
upon receipt of a statement from our office.
6. We will bill your insurance company for all services
provided in the hospital. You are responsible for any balance due.
I have read and understand the practice’s financial
policy and I agree to be bound by its terms. I also understand and
agree that such terms may be amended by the practice from time to
Signature of patient (or responsible party, if minor) Date
Please print the name of the patient
This site is intended for
informational purposes only. It is not a substitute for an office
visit. A visit to this site does not create a physician-patient
relationship. Actual physical contact between the patient and
the physician is required in order to make a diagnosis. Our office
is HIPPA compliant and any information entered here is secure.