Please read the Financial Agreement below before printing our Welcome Form.
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Financial Agreement
You are ultimately responsible for payment of fees for the goods and services we provide to you. Our
fees are adjusted periodically based on community standards for reasonable and customary rates. If
you are self-insured or do not have complete health insurance information, payment is due at the time
of service. For all others we will extend credit with the understanding that all charges are due and
payable within sixty (60) days following the date of service, even if your insurance company has not yet
paid.
In the event of insurance non-payment for any reason you are responsible for all outstanding charges.
Non-payment might occur because of an expired referral or the lack of a required referral. The service
might not be a covered benefit or the service may be denied for disputed medical necessity. Should
your insurance company pay for services after you have paid, you will be refunded any excess
payments.
We will bill your primary and your secondary insurance carriers provided that you provide complete and
accurate information necessary for us to do so. If you need additional time to pay on your account,
please contact our business office to arrange a payment schedule. Checks that are returned for
non-sufficient funds (NSF) will result in an additional $40.00 fee charged to your account.
Co-payments are always required by your insurance company to be made at the time of service. A
$3.00 billing fee will be added to all co-payments not made at the time of service and such fees may
not be billed to your insurer. You may bring cash, a check, a money order, debit card or Visa/Mastercard
with you if your insurance policy requires co-payments.
If you are a minor 16 years of age or older, unaccompanied by your parent or guardian, a signed and
dated authorization for care and assumption of financial responsibility must be provided by a parent or
guardian. If you are a minor under the age of 16 we are not able to provide services to you unless a
parent or guardian accompanies you.
If you have been referred to this office by your primary care provider and/or are referred for services
outside this office, you are responsible for obtaining all necessary referrals or authorizations required
by your health insurance company for payment. It is your responsibility to understand the requirements
of your particular insurance carrier. Failure to do so may result in financial penalties or responsibilities
to you and such penalties or responsibilities may be substantial.
It is your responsibility to keep your appointments with us. We require a full working day notice for office
appointment cancellations or reschedules. For example, a 2 PM appointment on Tuesday would need
to be cancelled prior to 2 PM on the preceding Monday. However, a 2 PM appointment on Monday
would need to be cancelled before 2 PM the preceding Friday. A fee of $30.00 is charged to your
account for late cancellations or no shows to office appointments. For overnight Sleep Studies, we
require two full working days notice of cancellation. Should you fail to notify us of cancellation of a Sleep
Study within two working days, or do not show up for your Sleep Study, a fee of $75.00 will be charged
to your account. We bill fees for missed appointments to defray the overhead cost associated with
staffing and facilities for your visit.
You may request a copy of your medical records on paper or by FAX. For all such authorized requests,
the following fees will be charged: $0.91 per page for the first 30 pages, $0.69 per page for all other
pages. If editing by the physician personally is required by statute, a basic office visit is charged. This
fee may not be billed to your insurance company. Fees are waived on a one-time basis when requests
are made within one year of your last visit and the request is for 10 copies or less.
If you request your clinician to write letters on your behalf for any reason, our charge is $25.00 per page
to cover transcription and handling costs and will take 10 working days to process. This fee must be
paid in advance and may not be billed to your insurance company. Alternately, a hand-written note,
composed during an office visit can be furnished at no additional charge.
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Click here to open our Welcome Form in PDF Format. You may print this form, fill it out, and bring it in
for your first appointment.
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