Thank you for choosing The Manhattan Center for Gynecology. We are committed to providing superior Medical care.
The following information is provided to avoid any miscommunication regarding payment for professional medical services. Please sign below that you have read and agreed to this policy.
• We accept cash or credit cards.
• All fees are based on the services rendered.
• Our fees are competitive for this region.
• If the patient is a minor (18 years or younger), the parent or guardian is responsible for payment of the account, in accordance with the policies outlined above.
• This policy covers all visits, procedures, elective or uncovered surgical services and balances for co-pays.
• Co-insurance, deductibles are due, prior to your testing/procedure/surgery. If you have reached your plan's limitations or should your insurance terminate during the time of services, you are financially responsible for all charges incurred.
• Unfortunately, if your account is overdue longer than 60 days, your account will be referred to the collection agency.
It is your responsibility to bring all required referrals for treatment at the time of your appointment or prior to your appointment. If you do not have a referral, you are financially responsible for any and all charges. If you do not have a referral then a credit card or cash payment is required at the time of your appointment or you may choose to reschedule your appointment. Please make sure we are notified of any changes with Insurance or demographic information.
We understand there are occasions when a patient must miss an appointment due to unforeseen circumstances or a scheduling conflict beyond her control. In this event, we ask that you call our office and cancel your appointment within 24 hours of the scheduled visit. This courtesy allows our staff to schedule another patient who is also in need of medical care. For your convenience, you may reschedule your appointment by calling us at 212-813-2146. Failure to notify us will result in the assessment of a Missed Appointment fee of $50.
Acknowledgement and Authorization
• I have read and understand the above payment policy agreement.
• I authorize my insurance benefits be paid directly to The Manhattan Center for Gynecology.
• I will forward any insurance checks to The Manhattan Center for Gynecology.
• I authorize The Manhattan Center for Gynecology to release any medical or other information to my insurance company requested.