Financial Payment Policy

Please provide us with your correct Insurance/ Medicaid information at the time services are rendered. If we do not receive the correct insurance information within 90 days from the date of service, you will be responsible for all charges. Intentionally providing false or misleading insurance information is a crime. Likewise, if you were to receive payment directly from your insurance company for a service that has not been paid by you, it is your responsibility to remint the insurance payment to our office.

Failure to show your insurance card or let us know of any changes will result in any and all bills becoming your responsibility. You are responsible at the time of service:

• To remit payment for any and all co-pays.
• To remit payment for any and all deductibles.
• To know your insurance policy. If your insurance covers immunizations and if services require a referral or prior authorization, please let us know.
• To know if your labs are covered and what facility to go to for your lab work.

If you are uninsured, payment is due at the time of service. If needed, we are willing to work with you on a payment plan. Ask to speak to our patient billing staff.

If you have health insurance, the contract to pay your benefits is strictly between you and your insurance company. If for some reason your health insurance company pays your claim and then retroactively denies the benefits, it is your responsibility to remit payment to us upon receipt of a statement.

If you decide not to present your information today, you will be considered a self-pay patient and will be expected to pay at today's visit.

By signing below, I hereby certify that all the information I have provided regarding my personal information and my health insurance information is true and correct as of this date. I understand that providing false information is a crime. I certify that I have been made aware of my responsibilities to ensure that the medical bills I incur are my medical bills and its my responsibility to ensure that these bills are paid. I fully understand that any unpaid debts will be sent to a professional collection agency and that any unpaid debts could adversely affect my credit.

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.