We are committed to providing you with the best care, your clear understanding of our financial policy is important; in saying this if you have any questions regarding our fees, policy or your responsibilities regarding your account please contact us.
All patients must have a complete and accurate Patient Registration Form on file with our office. Current insurance card must be presented at the time of service, including Medicaid and CHIP.
Full payment for services is DUE AT THE TIME THE SERVICE IS RENDERED; when your child is accompanied by some one other than the parent then payment must accompany the child. We accept Cash, personal checks pre-printed with all current information on the front of the check, American Express, Discover, MasterCard and Visa
We are not party to any legal agreements between divorced or separated parents. Whoever brings the child in for the appointment is responsible for payment at the time of service.
Your insurance policy is a contract between you and your insurance company. Please read your benefits so you will understand what type of coverage you have. We cannot guarantee payment of your claims by your insurer. Rejection of all or a portion of your bill by your insurance company does not relieve you of the financial obligation that you have incurred.
Returned Checks: There will be a $30 fee for all return checks. Cancellations and Missed Appointments: We require a 24 hour notice for all cancellations. If you do not show for an appointment or provide us with a 24 hour notice to cancel appointment, there will be a $25 fee for a missed/cancelled appointment.
Delinquent Accounts: All statements must be paid before or on the Due Date; accounts that are delinquent will have a $10 monthly fee assessed until the account is paid in full. Should your account become delinquent for nonpayment you will be reported to our collection service. Accounts must be current before future appointments may be scheduled. If you are unable to make your payment in full please call our billing office at: 972-370-2425 to make satisfactory payment arrangements.
I have read and understand the above policies and agree to accept responsibility for any financial obligations incurred.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Your Child. Your Trust. Our Commitment
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