NOTICE TO INSURANCE PATIENTS

As a courtesy, our office will bill your insurance company on your behalf for services rendered. If we are participating providers for your insurance plan, our reimbursement and your responsibility will be dictated by your insurance company. Although we are participating providers for many insurance plans, you will often still be responsible for a yearly deductible, office visit co-payments, and full responsibility for any charges allowed but not paid by your insurance company. Although we will bill your insurance company directly, the patient, not the insurance company, remains responsible for full payment of all allowed fees. Please understand that you are ultimately responsible for verification of your benefits and levels of coverage under your plan.

If we are unable to obtain payment from your insurance company within 60 days of your visit date, we will bill you for any unpaid charges. We will however, continue to assist you in obtaining reimbursement from your insurance company. Please be advised that patients with outstanding balances of greater than 30 days cannot receive additional services until your account is settled or other payment arrangements have been made with our office.

As a convenience, our office dispenses some generic medications, customized (compounded) prescription and non-prescription items. As our fees for these items are often considerably less than pharmacy charges or even pharmacy co-payments, you may find it advantageous to purchase these items in our office. Please be advised that payments for any products purchased in our office are generally not billable to your insurance company and are due at the time such products are dispensed. Should you prefer to receive written prescriptions simply inform us during your visit and we will provide you with a written prescription for the pharmacy of your choice.

Payment for medications and noncovered services is required at the time of the visit. Our office accepts credit cards (VISA/MC/AMEX), debit, and cash. Please be advised that we are unable to accept personal checks.

By signing below, I certify that I have read the above statement and agree to the terms stated herein.

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.