Thank you for the confidence you have placed with us by allowing us to participate in your healthcare. The following is a statement of our financial self-pay policy, which we require you to read and sign prior to treatment.
Your account is SELF-PAY at this time.
If you do have insurance, you must provide proof of the insurance card within 30 days of the date of service. All insurance claims must be filed in a timely manner. If we receive your insurance information after the timely filing deadline, the balance due will be your responsibility.
I have read and understand the above policies and accept my responsibilities as stated above. I agree to pay any and all charges.
We accept Cash, Checks, Visa, Mastercard, Discover, or American Express.