Patient Care Agreement Form
Our goal is to maintain efficient patient account management in a cost effective manner.
Visa, MasterCard, Discover, American Express accepted
Pay your Bill Online
Patient Accounting Hours: 8am to 4pm Monday through Thursday
Financial Counseling Services:
Our financial counselors will provide you with benefit information, preauthorization of services, personal financial responsibility information and budget payments.
Financial counseling services are open to all patients.
Financial counseling services are especially important if you are a surgical or obstetrical patient.
If we are in your health insurance booklet, a claim will be filed for you. Please be prepared to furnish your healthcare card and pay your portion at the time services are rendered.
If you have no healthcare coverage or coverage we do not participate with, please be prepared to pay for your services at the time services are rendered. We will file your claims as a courtesy to you and we will request that your insurance company pay you directly. **If you do not wish us to file claims on your behalf, please inform the checkout person.
We will assist you in any way possible to attain resolution from your insurance company.
You will receive a statement monthly when any activity takes place on your account.
You are requested to pay the patient portion listed on the statement upon receipt.
Refunds are issued twice monthly. Depending on when your overpayment occurs, your refund should be issued within a 30-day time frame.
We stress that insurance coverage is a contract between you and your insurance company. We are unable to determine if payment for your services will be made by your insurance. The ultimate financial responsibility for services rests with you.
**Any procedure visit or OB intake appointment not cancelled 24 hours prior to the visit will be charged a $25.00 No-show service charge.