Payment Policy: Please read, initial in front of each number and sign at the bottom
Thank you for choosing us as your primary care provider. We are committed to providing you with quality and a ffordable health care.
Becausesome of our patients hav had questions regarding patient and insurance responsibility forservices rendered, we have been advised
to develop this payment policy. Please read it, a sk us any questions you may have, Initial each space and sign at the bottom. A copy will be provided to you upon request.