• Patient Financial & Communication Consent

  • Patient Financial Policy

  • Payment is due at the time of service unless other arrangements have been made. Patients are responsible for copays, coinsurance, deductibles, and other amounts due. We accept VISA, MasterCard, Discover, American Express, cash, check, and CareCredit.

    Patients are responsible for required authorizations/referrals and for monitoring their insurance benefits. We may file assigned claims as a courtesy, but the patient remains responsible for balances not paid by the insurer.

    For plans without an agreement with this office, claims may be submitted on an unassigned basis and the insurer may pay the patient directly. Charges remain due at the time of service.

    Insurance plans vary. If a service is not covered or lacks required authorization, the patient is responsible for the full charge. Report insurance changes and authorization/referral requirements promptly; denied charges may remain the patient’s responsibility.

    Past-due accounts may be sent to collections, with collection, attorney, or court costs added to the balance. Returned checks are subject to a $35 service fee plus applicable bank NSF charges.

  • Email & Text Message Consent

  • We may contact patients by email and/or text for appointment reminders, feedback, and general health information.

    I consent to receive text messages at the cell number below, including messages sent to any number forwarded or transferred to that number.

    I consent to email and/or text communications as described above. This consent applies to future appointment reminders and general health information unless I request a change in writing.

    I may revoke this authorization by submitting a written request to the Office Manager. Disclosed information may be re-disclosed by the recipient and may not be protected by federal privacy regulations.

  • Format: (000) 000-0000.
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: