We are dedicated to providing the best possible care and service to you and regard your complete understanding of your financial responsibilities as an essential element of your care. The following is a statement of our Financial Policy in order to reduce confusion and misunderstanding between our patients and practice, which we require you to read and sign prior to any treatment. If you have any questions regarding these policies, please discuss them with our office manager.

• Unless other arrangements have been made in advance by either you or your health insurance carrier, full payment is due at the time of service. For your convenience we accept VISA, MasterCard, and Discover.
  
  
Your Insurance
• We have made prior arrangements with many insurers and health plans to accept an assignment of benefits. This means that we will bill those plans for which we have an agreement and will only require you to pay the authorized co-payment, deductibles and/or coinsurance at the time of service. It is our policy to collect this co-payment when you arrive for your appointment.
  
  
• If your insurance is one that we have an agreement with, but you do not present your insurance card at the time of service, you will be required to sign a waiver of responsibility and payment in full will be expected at the time of service. You will be given a receipt to file the services to your insurance.
  
  
• If it is discovered, after the fact that you did not present the current, correct insurance ID card at the time of service, you will be responsible for the charges if denied by your corrected insurance company as "past the filing deadline".
  
  
• If you have insurance coverage with a plan for which we do not have a prior agreement, we will provide you with a receipt that includes all the necessary information for you to file to your insurance company along with your personal health claim form. Your insurance company will send the benefit payment directly to you. Consequently, the charges for your care and treatment are due at the time of service.
  
  
• We do not file for SECONDARY insurance plans. We will file only for the primary plan if we are contracted with them. The patient is responsible to pay the copay assigned by the primary insurance and must file for their own secondary benefits.
  
  
• Payment in full at the time of service will be expected for COBRA plans. You will be given a receipt to file to your insurance.
  
  
• In the event that your health plan determines a service to be "not covered", you will be responsible for the complete charge. Payment is due upon receipt of a statement from our office. If you disagree with your insurance company's determination, you must contact your insurance company.
  
  
• HMO's and some other insurances require an official referral/authorization number or form. If the patient presents without this authorization form, and we have not received it in our office, you will be required to sign a Waiver of Responsibility Form and payment at the time of service will be expected.
  
  
• In the event of default on the patient balance owed, for any reason, the patient (or guardian) will be responsible for any and all collection agency fees, attorney fees, and court costs.
  
  
• As our policy is full payment at the time of service for your portion of the bill, we reserve the right to charge a $10 fee if you do not pay at the time of service and require us to bill you for your charges. _____________(patient/guardian initial)
  
  
Minor Patients
• For all services rendered to minor patients, we will look to the adult accompanying the minor for payment.
  
  
• Payment arrangements must be made in advance for unaccompanied minors.