Patient Forms

We value your time and ours. To help us provide timely care and keep appointments available for all patients, we ask for advance notice when changes are needed.

Cancellations & No-Shows
Appointments canceled with less than 24 hours’ notice, as well as missed appointments without notice, are subject to a $45 cancellation fee.

Repeated late cancellations or no-shows may affect a patient’s ability to schedule future appointments.

Emergencies
We understand that emergencies and unexpected situations happen. Consideration may be given in these circumstances. Please contact our office as soon as possible if this occurs.

We want to be transparent about payment expectations so there are no surprises. Please review the following information carefully.

Using Insurance

Your insurance policy is a contract between you and your insurance company. While we may be in-network with your plan and are happy to submit claims on your behalf, you are responsible for any applicable copays, coinsurance, and deductibles.

Please note that some insurance plans limit the number of covered visits or restrict coverage based on diagnosis codes. If your insurance company denies coverage, either partially or in full, you will be responsible for any remaining balance.

Self-Pay (Private Pay)

Patients who choose to self-pay are responsible for the full cost of services at the time they are rendered.

By electing to be a self-pay patient, you understand that services cannot be submitted to insurance for reimbursement.

Payment at Time of Service

It is our office policy to collect:

• Copays, coinsurance, and estimated deductibles at the time of service for insurance patients
• Full payment at the time of service for self-pay patients