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Thank you for
choosing us as your
health care provider.
We are committed to
your treatment being
successful. The
following is a
statement of our
Financial Policy that
we would like you to
read prior to any
treatment.
All patients must
complete our patient
information sheet
before seeing the
physician.
*DEDUCTIBLE AND
CO-INSURANCE ARE DUE
AT THE TIME OF
SERVICE.
*WE ACCEPT CASH,
CHECKS, VISA,
MASTERCARD OR
DISCOVER
We must emphasize
that as physicians
our relationship is
with you, not your
insurance company. We
file the insurance
claim as a courtesy
to our patients, but
all charges are your
responsibility from
the date the services
are rendered. Not
every service is a
covered benefit in
all contracts. Some
insurance companies
arbitrarily select
certain services they
will not cover. It is
important that you
read and understand
YOUR health insurance
policy and its
requirements for
coverage including
preauthorization of
services. We
currently send claims
to over 1700 plans
and are not
responsible for
knowing the
requirements of your
specific plan.
HMO, MANAGED CARE
AND PPO PLANS
Specific plans may
require referrals
from primary care
physicians. It is
your responsibility
to provide a current
referral form at the
time of your visits.
You are financially
responsible for any
services provided
without a referral
form.
MEDICARE
We do not accept
assignment on
Medicare and ask that
you pay for your full
charge at the time of
service. Any payment
from Medicare will
come directly to you.
We will bill your
secondary insurance
if you provide your
Medicare explanation
of benefits to us.
Medicare may forward
claims information to
the secondary.
PREGNANCY RELATED
CHARGES
Patient deductibles,
co-payments and
co-insurance amounts
are due prior to
delivery. We will
discuss payments with
you at your first
visit. If you have
questions before your
appointment, please
call.
SURGERY
PAYMENTS
An estimate will be
done at the time
surgery is scheduled
and you will be
responsible for
payment of any
deductibles,
co-payments or
co-insurance on the
preop visit.
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