PATIENT PAYMENT POLICY

Your insurance company may pay all, a portion or none of your bill for services provided. Because of this you are asked to assume responsibility for any uncovered balance on your account. Payment guidelines for office charges are as follows:

Insured Patients

• We bill all insurance plans, according to the insurance provided by the patient at time of service. It is your responsibility to give us updated insurance information.
• Your insurance company requires us to collect co-payments at the time of service. Waiver of copayments may constitute fraud under state and federal law. Please help us in upholding the law by paying your co-payment at each visit. Additionally, you may have coinsurance and/or deductible amounts required by your insurance carrier. Any outstanding balance on your account, after adjusting for all of your insurance’s responsibilities, will be billed to you.
• Payment in full is due at the time of service, for patients who do not provide a copy of their insurance card.
• Payment plans are not accepted for co-payments.
• Medical services that are considered by your insurance company to be non-covered, out of network, or not medically necessary will be your responsibility. Payment plans available for these services upon request.

Uninsured Patients

• You will be asked to pay for the services in full at the time of service. A 10 % discount will be given if paid in full at time of service. If you are unable to pay for the services in full, you will need to make a $100 deposit on your account and establish a payment plan with the billing department before your scheduled appointment.

All Patients

• Payment is to be paid in full within 30 days of receiving your statement. All billing disputes must be submitted in writing within 30 days of receipt of statement. All patient responsible balances that remain delinquent after 90 days may be referred to a collection agency with a 20% fee added to your balance for collection fees.
• Patients who directly receive insurance payments for services provided at our office are asked to send the check with EOB to our Billing Department as soon as possible.
• If you are unable to keep your appointment with us, please give us at least 24 hours notice. This courtesy enables us to offer your original time to another patient that needs to be seen. After three occurrences, without 24hours notice there will be a $25.00 charge.
• Checks returned to us from the bank for non-payment or insufficient funds, will be charged $25.00.

I have read and understand the above payment policy.