Thank you for choosing us as your health care provider. We are committed to your satisfaction. Please assist us in meeting your expectations by reviewing the Financial Policy below.
Forms: You will be asked to complete a registration form which will include your home address, telephone number, social security number as well as the address and telephone number of your insurance company, if applicable. Insurance company information can generally be obtained from a card provided to the company's insured member, and we prefer to make a copy and scan of the card for our records. We also request a copy of your driver's license or other picture identification to include in your record.
Forms of Payment: For your convenience, we accept cash and checks, as well as many credit and debit cards. We must have a copy of your driver's license to accept checks.
Office Visits: All office charges are payable at the time the service is rendered. If you desire, we will provide you with a copy of the superbill documenting the charges and receipts for your visit, which you may use to file for reimbursement with your insurance carrier.
Financial Responsibility for Minors: Unless prior arrangements have been made, charges for a minor child seen in the office will be the responsiblity of the adult accompanying the minor child.
Managed Care Plans: We are contracted with many managed care plans. We will file your insurance in accordance with our agreement with the plan. Any copayment or deductible for which you are responsible must be paid at the time of service.
Although we can assist you in many ways, it is your responsibility to be familiar with the coverage provided by your insurance plan, particularly with respect to preventive care, immunizations, the authorization of any procedures and your primary care physician. Please let us know when you call to make an appointment of any changes in your insurance coverage or plan. It will be your responsibility to make payment for any services not covered by your insurance company. If benefits and eligibility cannot be verified prior to service, you will be required to pay for services in full. Any charges denied by your insurance carrier will be your responsibility.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.