Patient Easy Pay Policy and Consent

Please correct the errors described below.

We will submit charges for your medical care directly to your insurer if we have a contract with that company.

All co-pays are due before your visit with the doctor. All over-the-counter products purchased thru the clinic are due upon check-out at your visit.

Please be aware that balances deemed patient responsible, either due to deductible, co-insurance or a non-covered service, may become due prior to your next follow-up visit. We accept for your convenience MasterCard, Visa, and Discover.

In order to continually give the highest quality healthcare we ask that any balance remaining on charges after your insurance company pays their portion be charged to your credit card/or health savings card. As a courtesy, we will call you before processing any charges on your credit card above $50.00. The information will be kept secure and confidential. You will receive a receipt via e-mail for any charges on your credit card or health savings card.

If you have a Health Savings Credit Card (HSA) we do require you to check the first box below and enter your card information.

*I also authorize my healthcare provider and/or any entity authorized by my healthcare provider, including those using automated dialing systems, automated messages, email, text messaging or other electronic communication to contact me for any reason by using any telephone number, email address and/or mailing address provided.

By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form.

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