CANCELLED, RESCHEDULED OR NO-SHOW APPOINTMENTS
- If an office visit appointment is not cancelled at least 24 hours in advance, you will be charged a $50 fee.
- If an office procedure or ultrasound appointment is not cancelled at least 24 hours in advance, you will be charged a $75 fee.
- If a surgery appointment is not cancelled at least 72 hours in advance, you will be charged a $100 fee.
INSURANCE
- It is the patient's responsibility to verify with their insurance company that we are participating providers.
- Your insurance may require additional information from you in order to process your claim. If they do not receive this information accordingly, you will be responsible for immediate payment.
- The patient is responsible for obtaining a referral/authorization from the Primary Care Physician of Insurance Company if required.
I HAVE READ AND FULLY UNDERSTAND THE ABOVE OFFICE POLICIES. I HEREBY AGREE TO RENDER PAYMENT IN ACCORDANCE WITH THE TERMS AND CONDITIONS SET FORTH.