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Patient Registration Information

Payment Policy

In order to keep our costs to you low, office visit charges and co-pays must be paid at the time of office visit. Please notify our receptionist if you have insurance so we can check your benefits and what your co-pay will be. You acknowledge if you have insurance that does not cover the cost of your office visit charges, you are responsible for all costs not covered by your insurance, agree to pay your balance in full, and authorize your credit card to be charged for any amounts not covered by insurance.

For your convenience, we accept cash, Debit/ATM cards, MasterCard (MC), Visa, American Express (AE), and Discover credit cards. In accordance with federal regulations, our privacy policy has been posted and you acknowledge your review. We assure your medical records are kept confidential and will not be released without your authority.

Please acknowledge your understanding and acceptance of our payment and privacy policies with your signature and date below.

Do you acknowledge your understand and acceptance of our payment policy?
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