Patient Forms & Financial Information

Financial Policy We will ESTIMATE your fees at the time of your consultation, based on information your insurance company has given us, but please remember that all quotes are subject to insurance policy ceilings in amounts determined by the individual policy. These ceilings are set by the policy, just as we set our own fees. Our fees are patterned after regional averages. PAYMENT OF YOUR PORTION, AS WE HAVE ESTIMATED, IS DUE AT THE TIME OF SERVICE. Any portion not paid for by your insurance company is your responsibility, and is due upon receipt of our statement. Any unpaid balances are subject to finance charges. WE DO NOT OFFER MONTHLY PAYMENT PLANS For your convenience we do accept the following methods of payment: 1. Cash, Check or Money Order 2. Visa, MasterCard and Discover 3. Loans may be available through Capital One and Citibank Programs include 12 months interest free to qualifying patients. Our team will make every effort to see you at your appointed time, so we appreciate your timely arrival. Appointment times are reserved expressly for you. If you cannot make your scheduled time, we require 24-hour notice to cancel the appointment and avoid possible broken appointment charges. I understand and agree the doctor's staff has been given some basic information about my insurance policy, but in no way expect them to know all the possible exceptions attached to my particular policy. I also understand that all quotes regarding insurance payments will be ESTIMATES. I am ultimately responsible for knowing my policy and paying any differences my insurance company does not cover. A dispute over insurance company payment is my responsibility to resolve with my insurance company. I have read and understand the payment policies of this office. Signature:_______________________ Date:____________