This form is subject to change/updated anytime and may require re-submit from a legal guardian
Payment is due at the time of service
Full payment is expected at the time of services as well as any past due balances.
Payment is due regardless of who brings the child in for the service, Grandparents, caregivers, aunts, etc.
It is the parent's/guardian's responsibility to notify the office of any address, phone, or insurance changes. Please have your insurance card with you at every visit.
For families in which parents are separated and/or divorced, the parent bringing in the child to the office is authorizing treatment and is, therefore, the parent responsible for payment on the date of service. If there is a divorce decree requiring the other parent to pay a portion or all of the treatment costs incurred, it is the responsibility of the authorizing parent to collect from the other parent. We can provide a copy of the claim or receipt of charges to the authorizing parent at each visit upon request to assist in the collection of fees from the other parent.
Insurance must be presented and active in order to utilize your benefits. If insurance cannot be determined as active, the patient will be considered Self Pay.
Self Pay patients - Visits are provided a discounted rate. Payment is collected at check in.
Your insurance determines if you have a copay, deductible and/or coinsurance.
Insurance co-payments are due at each and every visit. Please note that we are required by the insurance company to collect them. If your insurance plan has a deductible and it has not been met, you are required to pay for services. If your insurance does not pay for services provided, the parent/guardian is responsible for those charges. Verification of insurance is not a guarantee of payment; you are still responsible for all services provided to your child.
Acceptable payments include cash, check, Visa, MasterCard and Discover. A fee of $25.00 will be assessed to all returned payments.
No Show or Cancellation Fees less 24 hours prior to appointment time