Financial Agreement
It is the patient’s responsibility to check insurance benefits and coverage. You will be responsible for any non-covered services, deductibles, co-payments or co-insurances, as determined by your insurance carrier. Accounts unpaid by the insurance carrier greater than 90 days will be billed to the patient. Payments can be made via cards, such as credit/debt/FSA/HSA, or cash or check. There is a $35 fee for all returned checks. Cash-rate visit payments are due prior to your appointment.
Cancellation Policy
We request 24 hour notice for cancellation of appointments. Late cancellation or missed appointments are charged at $30. Please note that insurance companies will not cover missed appointment charges and, thus, this expense would be out-of-pocket for the patient.
Financial Agreement & Cancellation Policy Signature Form
HIPAA Privacy Policy
Patient HIPAA Signature Form
It is the patient’s responsibility to check insurance benefits and coverage. You will be responsible for any non-covered services, deductibles, co-payments or co-insurances, as determined by your insurance carrier. Accounts unpaid by the insurance carrier greater than 90 days will be billed to the patient. Payments can be made via cards, such as credit/debt/FSA/HSA, or cash or check. There is a $35 fee for all returned checks. Cash-rate visit payments are due prior to your appointment.
Cancellation Policy
We request 24 hour notice for cancellation of appointments. Late cancellation or missed appointments are charged at $30. Please note that insurance companies will not cover missed appointment charges and, thus, this expense would be out-of-pocket for the patient.
Financial Agreement & Cancellation Policy Signature Form
HIPAA Privacy Policy
Patient HIPAA Signature Form