All forms must be completed and signed prior to seeing the doctor.
We understand that some people may have some concerns providing specific information requested on our forms. Note that all information requested is required for payment, treatment or operations. Should this be of concern to you and you, for some reason, do not want to provide information requested, please be prepared to pay for all services required in full at the time of service or prior to any scheduled visits or procedures. Should you have any questions regarding this matter, please ask to speak with the office manager.
- ALL COPAYS, DEDUCTIBLES AND CO-INSURANCE FEES REPORTED BY INSURANCE COMPANIES ARE DUE PRIOR TO SERVICES RENDERED
- A $25 Penalty Fee Will Be Applied To Any "No Shows" or Copays Not Paid On The Date Of Service
- **For your convenience, we accept Cash, Checks, Visa, Discover and MasterCard**
- Return Check Or Charge Back Fee Is $35.00
- A $15 monthly rebilling fee will be included on all statements with patient balances over 30 Days.
Other Medical Forms
The completion of disability forms, FMLA forms, attending physician statements, and other supplemental insurance forms all require office supplies, physician and staff time to complete, therefore a $25.00 fee for each form will be charged and must be pre-paid. Note, there will be a 14 day turnaround time for completion, so make arrangements accordingly. Non-standard or multiple page forms may result in a higher rate.
If your insurance plan is a plan that requires a referral to be seen by a specialist, we ask that you obtain that referral directly from your primary care physician and bring it with you. This will prevent any appointment rescheduling or delays. Due to certain managed care requirements, we are unable to request or obtain patient referrals directly from the primary care physicians.
Due to the many types of insurance plans and policies, it is impossible for the provider to know your specific policy or plan requirements. Patients are responsible to know and understand all applicable insurance policies. In order to obtain accurate billing information we require a copy of your insurance card at the time of service. Note that we cannot file or accept assignment of your insurance unless proof of all insurance information is provided. Failure to provide sufficient insurance information at the time of service will result in payment in full until such time as adequate insurance information is provided.
If you have not received an explanation of benefit insurance payment (EOB) for services rendered within 45 days following your office visit or procedure, we ask that you contact your insurance company to see if additional information is required from you in order to process the claim. Based on some insurance policies beyond our control, any or all amounts paid for services rendered may not be applied to your in network benefits. Patients will be held responsible for any balance due upon notification from your insurance company that information has been requested and not received from you. Provider will not be held responsible for any portion of billed charges denied based on non-standard insurance payment methodologies or processed in non-compliance with state or federal regulations.
We do not participate with Medicaid, Therefore, all Medicaid Recipients will be financially responsible for all services rendered on or prior to the date of service.
Patients are seen by appointment only allowing both more convenience to the patient and opportunity for better care. We make a sincere attempt to adhere to the appointment schedule, but when emergencies and other circumstances arise beyond our control, they must take precedence and some delays may therefore occur. When you arrive at the office for your appointment, please check-in with the front office and provide any updated information since your last visit. By providing us with a telephone number, including a wireless phone number, you consent that calls may be made to that number for business or treatment related to services rendered. Failure to show or cancel a surgical procedure within 24 hours will result in a no show fee of $500.00 which will need to be paid prior to scheduling any further surgical procedures.
Prescriptions and Refills
It is not our policy to prescribe new medications over the telephone. Long term medications may be handled over the phone if you are up to date with follow up appointments and only during regular office hours. Please call your pharmacist with refill requests early to ensure completion of the refill approval process before 3:00 p.m. The pharmacist will contact our office for approvals. Refills or medications may not be provided without an office visit.
Our Physician or a covering physician will be on call and available for emergencies at all times, During office hours please call our office, identify yourself and relay your information to staff. After regular hours (4:30 p.m.) and on weekends, you will be provided with contact information for our answering service who will notify the provider on call of emergencies. Appointments, all medication refills and non-emergent calls will be held and handled during regular Business Hours (8:00 a.m. - 4:00 p.m.)