Copay Policy Form

At which office are you being seen?*
Name of Patient*

First NameLast Name
Date of Birth of Patient*

MonthDayYear
Date
Date of Office Visit

MonthDayYear
Date
COPAY POLICY FORM

Important Notice Regarding Your Copay.

All co-pays are due at the time of service. Non-urgent care may be subject to rescheduling when the co-pay is not paid. Please do not ask us to waive any co-payments; it is considered a breach of the insurance contract, and it can lead to denial of payment by the insurance company.

You are being granted a 24-hour grace period to make your copay payment.
● Payment must be received by the next day.
● Payments may be made:
○ By phone with a credit/debit card
○ Through the patient portal
○ You can go to our website and select pay online and pay for each child separately

If payment is not received within 24 hours, a $25 late fee will be applied to your account.
Acknowledgment

I understand that my copay was not collected at the time of service. I agree to pay my copay within 24 hours to avoid a $25 late fee.
Parent or Guardian Name (if other than patient who must be over 18)*

First NameLast Name
Signature of Parent /Guardian. If patient, must be over 18*
Date*

MonthDayYear
Should be Empty: