General Financial Terms

Services furnished to you or your dependents are charged directly to you and you are personally responsible for payment of all medical services. This includes, but is not limited to, charges for office visits, as well as all tests and procedures performed for you in this office. A fee schedule for all services I provide is available at my practice website.

I accept cash, personal checks, and credit cards (VISA, MasterCard) as payment. I will pass on to you any bank charges incurred and an additional $25.00 service charge for any returned check. If you have any financial difficulty making a payment, please contact me to make financial arrangements.

If you fail to pay your balance within 30 days after the statement was sent, I may assess a service charge of 1.5% of the remaining balance. Invoices not paid within 120 days are subject to patient dismissal, submission to my Collections Agency and notification to your insurance plan.

Self Pay

If you do not have medical insurance, payment in full is due at the time services are rendered, unless special arrangements are made in advance. A 30 % discount off published fees is available to self-pay patients that pay charges in full at the time of service.

Credit Card Authorization

For your convenience in paying the balance on your account, I ask all patients to complete a Credit Card Authorization Form annually. This form will be used so that I may automatically bill your account for outstanding balances. You will only be charged when there is a patient balance owing on your account. You may specify a maximum dollar amount that I am authorized to charge each month. By filling out this form, you allow me to spend less time and effort collecting outstanding balances and have more time to focus on your healthcare needs. Additionally, this will in no way compromise your ability to dispute a charge or question your insurance company’s determination of payment.