We are committed to providing you with the best possible care, and we are pleased to discuss our professional fees with you at any time. Your clear understanding of our Financial Policy is important to our professional relationship. Please ask if you have any questions about our fees, Financial Policy, or your responsibility.
I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and me. If you have Health Insurance; we will bill them as a courtesy and assist you in receiving the maximum reimbursement benefits possible. Furthermore, I understand that Dr. Masulas’ Office will prepare any necessary reports and forms to assist me in making collection from my insurance company and that any amount authorized to be paid directly to the Doctor’s Office will be credited to my account on receipt.
However, I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate, any fees for professional services rendered me will be immediately due and payable. The patient also agrees that he/she is responsible for all bills incurred at this office.
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