Payment Policy Form

Payment Policy

The filing of insurance claims is a courtesy we extend to our patients. We are happy to assist you in billing most insurance companies. However, we must emphasize that your insurance is contract between you and your insurance company. We are not party to that contract.

Many of the services provided in this office are covered and paid by your insurance company. In cases where the service has not been paid, you will be personally responsible for the balance. If the patient is a minor, the person brings the minor to the office for treatment is responsible for payment of the bill.

Payments for services are due at the time service is rendered.

We accept cash, checks and all Visa or MasterCard. To assist you in making payments if special circumstances arise, we would be happy to arrange an automatic debt payment schedule to facilitate regular agreed upon payments.

Summary of Notice of Privacy Practices

This summary is provided to assist you in understanding the attached Notice of Privacy Practices

The attached Notice of Privacy Practices contains a detailed description of how our office will protect your health information, your rights as a patient and our common practices in dealing with patient health information.

Uses and Disclosures Based on Your Authorization

We will use and disclose your health information in order to treat you or to assist other health care providers in treating you. We will also use and disclose your health information in order to obtain payment for our services or to allow insurance companies to process insurance claims for services rendered to you by us or other health care providers. Finally, we may disclose your health information for certain limited operational activities such as quality assessment, licensing, accreditation, and training of students.

Uses and Disclosures and Disclosures Not Requiring your Authorization

In the following circumstances, we may disclose your health information without your written authorization:

  • To family members or close friends who are involved in your health care.
  • For certain limited research purposes.
  • For purposes of public health and safety.
  • To Government agencies for purposes of their audits, investigations and other oversight activities.
  • To government authorities to prevent child abuse or domestic violence.
  • To the FDA to report product defects or incidents.
  • To Law enforcement authorities to protect public safety or to assist in apprehending criminal offenders.
  • When required by court orders, search warrants, subpoenas and as otherwise required by the Law.

Patient Rights

  • To have access to and/ or a copy of your health information,
  • To receive an accounting of certain disclosures we have made of your health information.
  • To request restrictions as to how your health information is used or disclosed.
  • To request that we communicate with you in confidence.
  • To request that we amend your health information.
  • To receive notice of our privacy practices.

Acknowledgement of Reciept of Notice of Privacy Practices

I acknowledge that I was provided a copy of the Notice of privacy Practices and that I have read and understood the notice.