PAYMENT POLICY

We are committed to providing you with the best possible care. In order to achieve these goals, we need your assistance and understanding of our payment policy. If you have medical insurance, we will assist you in receiving your maximum allowable benefits. Payments for services are due at the time services are rendered unless payment arrangements have been approved in advance by our staff. We accept Cash, Check, Visa and MasterCard.

We will be happy to file all primary insurance for you as a courtesy. However you must realize:

1. Not all services are covered by insurance contracts, i.e. radiology reports, some blood work, massage, etc. If your insurance determines your visit and/or massage are not medically necessary, you will be responsible for services rendered.
2. All charges are your responsibility for the date/dates the services are rendered.
3. All co-pays are due at the time of service.
4. There is a $45 charge for returned checks. (fee subject to change)
5. Patient balances over 60 days old will be assessed a 1.5% per month charge on outstanding balances.
6. There will be a $30 missed appointment fee charged to your account without 24 hour notice of cancellation for the 1st missed appointment.
7. Additional missed appointments will be charged the full rate of the appointment.

The Patient and the Responsible Party hereby agree to be fully responsible for any and all amounts and charges submitted by the Physicians in the course of treatment or any of their agents, employees, or contractors. Patient and the Responsible Party acknowledge that the charges may exceed the amount your insurance carrier may define as “usual and customary, or reasonable”, (does not include insurances that have their own set fee schedules) but the Patient and Responsible Party agree to pay the amount of such billed charges.

This form will be retained in your health record.