PRACTICE CODE OF CONDUCT
Reasons you may be discharged from our service:
- Rude or violent behavior to our staff via in-person or telephone – this also applies to your family members and/or friends.
- Repeated no shows, cancellations, or continual late arrivals of appointments
- Refusal to adhere to the plan of care as outlined by your clinician of to follow health insurance or government guidelines
Please read and Initial each of the following:
Co-Pay: Your insurance may require a co-pay. It is your responsibility to know what your co-pay is. Payment will be collected at the time of service.
Cancellation Policy: We require a 24-hour notice for cancellations. If you do not give 24-hour notice or No-Show for your appointment you will be charged a $75.00 fee. Fee must be collected prior to making anymore appointments.
Insurance: If you do not provide us with current insurance at the time of each visit, you will be responsible for the bill. You are responsible for obtaining the appropriate referral from your Primary Care Physician. If your insurance denies your claim for lack of referral, you are responsible and must pay for services rendered.
Return Check Fee: $35.00 fee for each incident
Certification/Agreement/Assignment of Benefits:
I certify that the above information is accurate complete and true. I understand that this will become part of my medical record. I hereby assign all medical and surgical benefits and authorize my insurance carrier(s) to issue payment directly to the Practice. I understand that I am financially responsible for all services I receive from the Practice.
