We are pleased that you have scheduled your appointment with our practice and look forward to meeting you. Please complete the paperwork shown here and bring it with you to your appointment. Please make sure that you arrive at our office at least 20 minutes prior to your appointment to allow us sufficient time to process your paperwork. If you forget to bring your completed forms with you, please arrive at least 30 minutes prior to your appointment.

A copy of these documents becomes a part of your permanent record. If you have insurance changes please notify the office as soon as possible. There are a very large range of policies, therefore your coverage terms will probably change considerably. We would also like to confirm that we are in-network providers for your plan.

Again, we look forward to meeting you, providing you with the best in healthcare and establishing a long-term relationship.

What You Should Know About Your Insurance Before Your Visit

As a courtesy to our patients, our office attempts to verify your insurance coverage prior to your office visit. Unfortunately, the information we receive from your insurance company is minimal and is not a guarantee of coverage or benefits, but rather a quote based on current eligibility.
In general, we are not given specifics of your coverage; for example, what procedures you’re insurance does/does not cover. We verify eligibility, co-insurance, and copay amounts only. If you elect to have a procedure performed at a future date, our office will verify benefits prior to the procedure.
We strongly encourage all patients to “know” their insurance policy. It is important to have this information because you are responsible for paying all charges associated with your care which the insurance does not cover at the time of service. Knowing what your plan does/does not cover will provide you with the knowledge/power to make medical decisions and to know your options. Also, you are more likely to receive the maximum benefits allowed by your policy if you are aware of what your coverage entails.
Be sure to bring your insurance card, as this is necessary to file a claim on behalf of your visit. Please note that if you do not bring your insurance card with you, payment in full is expected at the time of service. You will also need to bring your driver’s license/photo id and method of payment for your co-insurance/copay. We do not file insurance on indemnity plans.
Please feel free to contact our office if you have additional questions prior to your appointment. Thank you for helping us make your visit more enjoyable!

Financial Responsibility

We are committed to providing you with the best possible care. If you have medical insurance, we are eager to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and your understanding of our payment policies.
Payment for services not covered by your insurance plan and any out of pocket expenses are due at the time of service. Our office collection policy supersedes any other contract language or statements in managed care contracts or other insurance policies. We accept checks, cash, debit cards, MasterCard, Visa, and Discover. We will be happy to file your insurance if you are a member of one of our managed care plans. We do not file claims on insurance plans with which we do not participate.
Returned checks are subject to an additional collection fee of $25.00. We will gladly answer questions regarding your insurance. You must realize, however, that:

Your insurance is a contract between you, your employer and the insurance company. We are not a party to that contract.

We will file your insurance on plans we participate with only if we have the necessary information to verify your benefits.

Our fees are generally considered to fall within the acceptable range of usual and customary by most companies, and therefore, are covered up to the maximum allowable determined by each carrier.

Not all services are a covered benefit in your contract. Some insurance companies arbitrarily select certain services they will not cover or may set maximum limits. These amounts are your responsibility.

We must emphasize that as a medical care provider, our relationship is with you, not your insurance company. While the filing of insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date services are rendered. It is understood that temporary financial problems arise; you are encouraged to contact us promptly for assistance in the management of your account. If you have any questions regarding the above information, please do not hesitate to ask.
It is necessary to bring:
  • Driver’s license
  • Insurance card
  • List of medications currently being taken
  • Name and phone number of your pharmacy
For pediatrics patients, please bring:
  • Proof of insurance