Authorization for release of information:
I authorized a release of my protected health information to
If you are self pay patient, you will be required to pay for
the office visit before services ate rendered.
In addition, any remaining balance on your account will be
collected at discharge.
If you are an insurance patient, it is our policy to file
for insurance as a courtesy to you, if we have accurate and complete insurance
Deductibles, Co Payments and co-insurance will be collected
at the time of services and or due within 60 days of insurance processing. Non
covered services by your insurance company will be your responsibility at the
time of services.
help in this policy, we ask that you assist us by
us with current and updated information on yourself and your insurance company,
- Present an updated photo identification card and
insurance card when changes are made.