Office Policy

Insurance is a contract between you and your insurance company. Your doctor is contracted with most local insurance plans. It is your responsibility to make sure your doctor is a contracted provider with your insurance. Although we may estimate what your insurance may pay, it is the insurance company that makes the final determination of your eligibility.

You agree to pay any portion of the charges not covered by your insurance. If your insurance requires a referral and/or precertification, we will assist you, but it is your responsibility to make sure this has been done prior to the date of treatment. Failure to obtain the referral/precertification may result in lower payment by your insurance company. If your insurance does not pay within 45 days, you will be required to start paying on your account.

1. You can choose to pay your deductable and any out-of-pocket portions at the time services are rendered by cash, check, or credit card.
2. If financial arrangement is needed, you may choose to pay 50% at the time of service and the balance in three weeks.

1. You can choose to pay by cash, check, or credit card on the day that treatment is rendered.
2. If financial arrangement is needed, payment options should be discussed with the office manager.
3. You may prefer to secure other third-party financing for the entire amount, and make payments to the lending institution.

We shall have the right to cancel your privilege to make charges against your account at any time. Future visits would then need to be paid for at the time of service.

A request for special forms will incur a charge. The following are "special" forms and payable to the office prior to release of information: Short term disability form $25.00, Long term disability form $35.00 and FMLA form $50.00.

In case of a divorce or separation, the party responsible for the account prior to the divorce or separation remains responsible for the account. After a divorce or separation, the parent authorizing treatment for a child will be the parent responsible for those subsequent charges. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent's responsibility to collect from the other parent.

If you have a balance due on your account, we will send you a monthly statement.

If your account becomes past due, we will take necessary steps to collect this debt. If we have to refer your account to a collection agency, you agree to pay all the collection costs which are incurred, plus a late fee of $20 will be applied for missed payments.

The balance on your statement is due and payable when the statement is issued, and is past due if not paid withing 15 days, unless other arrangements are approved.

If financial arrangement is needed, payment options should be discussed with the office manager.

Any co-payments required by an insurance company must be paid at the time of service. Because this is an insurance requirement, we cannot bill for these.

There is a fee (currently $30) for any checks returned by the bank. You agree to pay this fee plus the amount of the returned check by cash, money order, certified check, or credit card within 15 days.

You understand that if this account is submitted to an attorney or collection agency, if your past due status is reported to a credit reporting agency, the fact that you have received treatment at this office may become a matter of public record.
Contract Lab: We currently have an agreement with Lab Corp. It is your responsibility to know which lab your insurance is contracted with.
Cobra: If at any time during your care, your insurnace benefits are considered to be COBRA, we need to be notified immediately. You must provide proof of current coverage. You will be responsible for payment in full if your insurance company cannot verify coverage for the dates of treatment.

The third time a patient does not show up on time for an appointment, or cancels with less than 24 hours notice, a $20 fee may be charged. We will not file this fee to your insurance company; you are responsible. Patients with four missed appointments may be asked to transfer their records to another doctor.

You will need to sign and pay a reasonable fee ($25) if you want copies of your records sent to another doctor or organization. You authorize us to release all relevant information. This may include your payment history if used for legal purposes.

In special circumstances a co-signature may be required. If this or another Financial Policy is signed by another person, that co-signature remains in effect until cancelled in writing. If written cancellation is received, it becomes effective with any subsequent charges.

As a courtesy to all patients, requests for prescription refills are filled at your annual visit. If you need your prescription refilled, have your pharmacy fax us a request – (972) 473-2077. You will need to have your prescription information available for the pharmacy.

Refills must be called in at least 48 hours in advance to avoid interruption in your care. Routine prescriptions are not considered an emergency and generally will not be refilled after normal business hours, by our on call physician, on weekends, or on National Holidays

We do not accept new patients for workers compensation claims. We require written approval/authorization by your employer and/or worker's compensation carrier prior to your visit. If your claim is denied, you will be responsible.