Financial Policy

Thank you for choosing us as your health care provider. We hope that we are able to provide your medical care in a way that is comfortable and convenient for your. If there is any way that we can be of better service, please do not hesitate to let us know.

With regard to payment for services rendered, my office has established certain policies. We will gladly bill your insurance for any and all fees. We ask, however, that you pay a portion of your charges at the time that the services are rendered. New and established patients are required to pay 20% of total charges on the date of service. We will bill your insurance for all charges and will gladly provide you a refund I f necessary after we have received payment from your insurance company. This will allow us to help keep fees lower by eliminating costly multiple billings, If you have an HMO,PPO or Medical Assistance, your co-pay is sue prior to treatment. We accept payment with cash, dept card, check or credit card.

If you have no insurance, payment in full is expected at time services are rendered. If you have some special financial circumstances that would prevent you from paying your bill in full, or if you are an obstetrical patient, please discuss it with my staff prior to the day of your visit so alternate arrangements can be made for you.

Our office also has a cancellation policy. To reschedule or cancel appointments ple4ase notify us. We reserve the right to charge $25.00 for failed appointments.

Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rate.

Thank you for your kind consideration in this matter.

I have read the above financial policy and understand my financial obligations.

X___________________________________________
(Signature of patient or responsible party)

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