Effective July 22nd, 2025
FINANCIAL RESPONSIBILITY/ASSIGNMENT OF BENEFITS
I acknowledge full financial responsibility for any services rendered and I understand that the payment of charges incurred in this office are due at the time of service. I also understand that the charges not covered by insurance remain my responsibility and assign insurance benefits to this office. In the event my account is turned over to a collection agency, I agree to pay all costs of collection fees and/or attorney’s fees and all court costs if any. If I am not using insurance, I will pay for all charges in full today according to the Self-Pay pricing schedule available in the clinic. If I am using insurance, I agree to pay today, at the time of service, my urgent care benefits, copays, coinsurance and deductibles. If I have an insurance deductible that has not been met, I agree to pay in full at the time of service. If paying with credit, I understand and agree that card info may be ‘stored on file’ and charged for any patient liability amounts incurred today or in the future, after my claim is processed by insurance. I will receive an EOB (Explanation of Benefits) from my insurance company after each visit and I agree to pay upon receipt of the bill. I agree that I will be charged no-show of $50 in the case an appointment is missed without any prior communication or a cancellation fee of $50 when appointment is cancelled within 24 hours of the appointment. In the case of legitimate emergencies or extenuating circumstances, the fee may be waived and will be reviewed on a case by case basis and under the discretion of the practice. I agree to be contacted at any telephone number or email address associated with my account. This includes cellular telephone numbers or other wireless devices. I understand this could result in a charge from my phone or device carrier to me for talk time, SMS messaging/texts or data usage for emails or voice mails. I also understand methods of contact may include pre-recorded /artificial voice messages and/or the use of automatic dialing devices as applicable.
CONSENT FOR TREATMENT
I, the undersigned, consent to the care and treatment by the Physician and his/her associates or assistants and acknowledge that no guarantees have been made as to the effect of such treatment.
