Terms and Conditions
FINANCIAL POLICY/ MISSED APPOINTMENT CHARGE
Payment is required at time service is rendered. Returned checks are subject to a service charge.\nA minimum of 48-hours advance notice is required if a patient must cancel or reschedule their appointment.\nA missed appointment fee will be charged for missed appointments without the minimum 48-hour notice.
ASSIGNMENT OF INSURANCE BENEFITS
I hereby authorize direct payment of surgical/medical benefits for services rendered by the Physician(s) in person or under Physician(s) supervision. I understand that I am financially responsible for any balance not covered by my insurance company, or any service my insurance company deems not covered by my policy.
AUTHORIZATION TO RELEASE OR OBTAIN INFORMATION
I hereby authorize my providers to release or obtain any medical or incidental information (to include HIV testing and/or treatment records, substance abuse, and/or Psychiatric care or treatment) that may be necessary for either medical care or in processing application for financial benefit.
ACKNOWLEDGMENT OF RECEIPT OF PRIVACY NOTICE AND REQUEST TO RESTRICT/EXCEPTION TO RELEASE PROTECTED HEALTH INFORMATION
We are required by law to provide you with a copy of our Notice of Privacy Practices. Should you wish to allow or restrict access of your medical records to person(s), please inform an office personel.