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Payment Policy Form

Payment Policy

It is the policy of this office to receive payment at the time services are rendered unless other arrangements have been made.

Payment options are:

  • Cash
  • Check
  • Visa
  • MasterCard
  • Discover
  • American Express
  • Care Credit

Claims rejected by your insurance carrier will be the patient’s obligation and payment arrangements should be made with the Business Manager.

It is the patient’s responsibility to know all insurance coverage and deductibles that may apply to any and all services rendered in this office.

In the event your account becomes delinquent and is turned over for collections, the patient agrees to pay all collection and/or attorney fees plus all legal court costs.

Any missed appointments without cancellation calls within 48 hours’ notice will be billed to the patient in full.

Signature and Date Below

Payment Policy Confirmation
Policy Consent Signature Print Name(Required)
MM slash DD slash YYYY

Signature and Date Below

Assignment Confirmation
Assignment Confirmation Signature Print Name(Required)
MM slash DD slash YYYY