Office Policies

The following are office policies. Patients will need to sign these when registering as a patient.

Insurance Policy

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I hereby authorize this physician to apply for benefits on my behalf for covered services rendered. I certify that the information I have reported with regard to my insurance coverage is correct, I further authorize the release of any necessary information, including medical information for this or any related claim, to my insurance carrier, (or in the case of Medicare part B benefits to the social security administration and healthcare financing administration). I hereby authorize payment of all medical insurance benefits which are payable to me under the terms of my insurance policy to be paid directly to this physician for services rendered. I further authorize the release of any information needed for processing of my insurance claims. A copy of this authorization may be used in the place of the original. I understand and agree that I am financially responsible for all charges not paid by my insurance company. This authorization may be revoked by either me or my insurance carrier at any time in writing.

Financial Policy


In order to establish optimal relations with our patients and avoid misunderstanding and confusion regarding our payment policies, our staff is trained to consistently inform you of the financial payment policies of this office. Payment is required for all services at the time they are rendered unless you are in a prepaid plan in which we participate. For those patients, applicable copayments and deductibles are collected. We accept payment in the form of cash, check, or credit card. In the event that an appointment is not cancelled within 24 hours, you will be charged a $50.00 fee.

Medicare Policy


I understand that in certain circumstances Medicare may decide that appropriate medical services are not medically reasonable or necessary under the Medicare law. I agree to be personally responsible for payment of these charges.

Charges for Patients without Insurance


We do offer a reduced non-negotiable rate for patients without health insurance. Payment must be made at time of service. This rate does not apply to claims submitted to insurance and then applied towards a deductible. It is against our insurance contracts to reduce the amount due from deductible.

HIPAA notice


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