| THIS CLINIC IS NOT A PARTICIPATING PROVIDOR FOR ANY INSURANCE CARRIER. Your insurance is an agreement between you and your insurance company, not between your insurance company and our clinic. It is understood and agreed that services rendered are charged to you directly and payment is expected at the time of services. We will provide you with instructions and a super-bill so that you may file an insurance claim with your insurance company to receive reimbursement.
It is imperative that you understand the following conditions and agree to them:
1. You are required to sign the informed consent agreement, financial agreement, and medical records release forms as well as any other assignment documents required by your insurance company and our office.
2. If you are to be reimbursed by your insurance carrier it will likely be within 30 days of your office visit. If your insurance has not paid or you have not received an explanation of benefits within 30 days, please contact your insurance company.
3. You are required to pay for all services provided to you at each visit. Any past due accounts are subject to a 20% annual fee.
4. Our office will not enter into a dispute with your insurance company over any claim. This is ultimately your responsibility and obligation.
5. Our office cannot guarantee that your insurance company will pay.
6. The doctor and patient and/or their representatives in advance of care must sign any special arrangements regarding finances.
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