Here you will find important information about our financial policies.

Charges To Account
We shall have the right to cancel your privilege to make charges against your account at any time. Future visits would then need to be paid for at the time of service.

Disability Forms
A request for special forms will incur a charge. The following are “special” forms and payable to the office prior to release of information: Short term disability form $25.00, Long term disability form $35.00 and FMLA form $50.00.

Divorce
In case of a divorce or separation, the party responsible for the account prior to the divorce or separation remains responsible for the account. After a divorce or separation, the parent authorizing treatment for a child will be the parent responsible for those subsequent charges. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent’s responsibility to collect from the other parent.

Monthly Statements
If you have a balance due on your account, we will send you a monthly statement.

Past Due Accounts
If your account becomes past due, we will take necessary steps to collect this debt. If we have to refer your account to a collection agency, you agree to pay all the collection costs which are incurred, plus a late fee of $20 will be applied for missed payments.

Payments

• The balance on your statement is due and payable when the statement is issued, and is past due if not paid within 15 days, unless other arrangements are approved.
• If financial arrangement is needed, payment options should be discussed with the office manager.

Required Payments
Any co-payments required by an insurance company must be paid at the time of service. Because this is an insurance requirement, we cannot bill for these.

Returned Checks
There is a fee (currently $30) for any checks returned by the bank. You agree to pay this fee plus the amount of the returned check by cash, money order, certified check, or credit card within 15 days.

Waiver of Confidentiality

• You understand that if this account is submitted to an attorney or collection agency, if your past due status is reported to a credit reporting agency, the fact that you have received treatment at this office may become a matter of public record.
• Contract Lab: We currently have an agreement with Lab Corp. It is your responsibility to know which lab your insurance is contracted with.
• Cobra: If at any time during your care, your insurance benefits are considered to be COBRA, we need to be notified immediately. You must provide proof of current coverage. You will be responsible for payment in full if your insurance company cannot verify coverage for the dates of treatment.