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Thank you for choosing us as your health care provider.
We are committed to building a successful physician-patient relationship with you and your family. Please understand that payment for services is part of this relationship. The following information outlines our financial policy.
Payment due at the time of service: Co-payments, deductibles, co-insurance and non-covered services are due at the time of service. Acceptable methods of payment are cash, money order, Visa, MasterCard and American Express.
Account balance: A statement will be issued for unpaid balance, payment for balance is due within 30 days of statement date.
Account past due: If payment is not received within 60 days account will be consider past due and may be turned over for collection. Patient or Guarantor will be responsible for all costs of collection monies owed, including court costs, collection and attorney fees. I further understand that if I fail to make any of the payments for which I am responsible in a timely manner, I will be charged a 1.5% service charge monthly on the remaining balance.
Insurance Updates: We are pleased to assist you by billing for our contracted insurers. However, the patient is required to provide us with the most correct and updated information about their insurance, and will be responsible for any charges incurred if the information provided is not correct or updated.
No-Show Policy: A "no-show" is someone who misses an appointment without cancelling it in an adequate manner. "No-shows" inconvenience those individuals who need access to medical care in a timely manner. A failure to present at the time of a scheduled appointment will be recorded in the patient's chart as a "no-show". The first time there is a "no-show", there will be no charge to the patient. Any additional "no-show" will result in a fee of $50.00 billed to the patient's account.
General Consent for Treatment
I, hereby authorize, Dr. Diana Gorokhovsky, and other center employees, to examine and treat me.
I also authorize such treatment and procedures, as deemed necessary by the physician, including but not limited to, taking of such x-ray, medications, blood samples, urine samples, and other therapies as deemed necessary.
I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantee or assurance has been made or implified to me as to the results that may be obtained by examination and treatment.