FINANCIAL POLICY
• If you do not have insurance, you must pay for your visit in full.
• If you do have insurance and we are a participating provider, we will file it for you.
• If we have filed your insurance twice, and they have not paid, you will be responsible for payment.
• There is a $35 fee for returned checks and redepositing a check.
• Anything that your insurance does not cover or denies, you will be responsible for.
• The parent and/or guardian bringing a minor patient in is responsible for making the payment that is due on the
patient’s account.
• Please give a 24 hour notice if you need to cancel or reschedule an appointment. Canceled appointments less than 24
hours and missed appointments will be subject to a $25 fee. A second missed appointment will be subject to a $50 fee and a
third missed appointment will result in dismissal from this practice.
I HAVE READ AND UNDERSTAND THE PATIENT PRIVACY ACT, THE FINANCIAL POLICY AND NOTICE OF PRIVACY PRACTICES OF WOMEN’S HEALTH ASSOCIATES. I CONSENT TO MEDICAL TREATMENT AND UNDERSTAND THAT THIS AGREEMENT IS IN EFFECT FOR ONE YEAR UNLESS REVOKED IN WRITING BY MYSELF.