We are honored that you have chosen us as your healthcare provider. Our goal is to provide the highest quality care for all of our patients in a timely and respectful manner. Below you will find the required forms to be completed prior to your initial visit.
All Services: Complete and Bring these Required Forms
NEW PATIENT INFORMATION
Remember to bring the forms above and the following to your first appointment:
▪ Your insurance card (if applicable)
▪ Your driver’s license
Payment for service is due at the time of service unless payment arrangements have been approved in advance by our practice manager. We accept credit cards, checks, cash and money orders. We also accept Health Saving Account (HSA) and Flexible Spending Accounts (FSA). We may offer to process your insurance claim depending on services provided, and it is your responsibility to provide us with full and accurate information at the time of service.
Our relationship is with you and not your insurance company. Co-pays are due at the time of service. For your convenience, your co-pay can be paid prior to your arrival by utilizing the Online Bill Pay.
Please be aware that some insurance companies will pay a claim percentage based on the “usual and customary” not on your actual charges. The difference between what we bill and what they pay is your responsibility.
Private pay accounts are expected to pay at the time of service. Pre-arrangements may be made with my practice manager prior to the appointment. Patients may be dismissed from the practice for failure to follow the financial agreement. Please refer to Members Service Guide.
Delinquent accounts will be referred to a collection agency at our discretion. If our collection agency or if we take any legal action, the non-prevailing party agrees to pay the legal costs.
A $25.00 fee will be charged for repetitive (3 or more) appointments missed without notice. Please refer to the Medical Appointment Cancellation Policy.