Patient Financial Policy

Thank you for choosing us as your health care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered part of your treatment. The following is a statement of our Financial Policy, which we require you to read and sign prior to any treatment.
All patients must complete our information and insurance form before seeing the doctor.

Regarding Co-payments
Unless you know specifically what type of insurance plan you have and you can provide:
I. An insurance form stating the insurance you have.
2. A copy of the benefits from your insurance.
Only then will you not be responsible for a co-payment at the time of service.
If you are only covered a percentage from your insurance, you will be responsible to pay the other percentage not covered. (For example if you are covered 80%, then you will have to pay the 20% not covered).

Missed Appointments
Unless canceled, at least 24 hours in advance, our policy is to charge for missed appointments at the rate of the normal office visit. Please help us serve you better by keeping your scheduled appointments.

Minor Appointments
The adults accompanying a minor in the office for treatment must stay with the minor at all times. Payment is expected at the time of the service, whether it is payment in full, a percentage, or a deposit.

Patients are responsible to know their insurance information such as:

1. Name of the insurance
2. Subscriber
3. ID number
4. Address
5. group number (if needed)

We are not responsible for insurances that deny any claims. Your insurance policy is a contract between you and your insurance company. As a courtesy, we will file your insurance claim for you if you assign the benefits to the doctor. In other words, you agree to have your insurance company pay the doctor directly. If your insurance company does not pay the practice within a reasonable period, we will have to look to you for payment. If we do not receive payment from you either, then your account will be placed in a delinquent status and sent to a collection agency. All health plans are not the same and do not cover the same services. In the event your health plan determines a service to be “not covered,” or you do not have an authorization, you will be responsible for the complete charge. We will attempt to verify benefits for some specialized service; however, you remain responsible for charges to any service rendered. Patients are encouraged to contact their plans for clarification of benefits prior to services rendered.

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