TERMS OF SERVICE

OFFICE PROCEDURE

Please provide this office with all accurate insurance information with a valid, current copy of your insurance card, a copy of your photo ID, and credit/debit card information at the time of service. It is your responsibility to notify us of any changes to your health coverage. Our office will file your claim; however, you are responsible for ensuring payment from your insurance company. This office accepts cash, check, credit card. There is a $30 service charge for returned checks. Payment is due at the time of service. No exceptions.

Privacy Practice (HIPAA): We understand the importance of privacy and are committed to maintaining the confidentiality of your medical information. Below briefly describes how we may use and disclose your medical information: (1) We use medical information about you to provide your medical care. (2) We use and disclose medical information about you to obtain payment for the services we provide from your insurance company. (3) We may use and disclose medical information about you to operate this medical practice.  (4) We may use and disclose medical information to contact and remind you about appointments, office notices, and give you information about products or services related to your treatment. For more details about our privacy practice, please see NOTICE OF PRIVACY PRACTICE. Notice of Privacy Practice is available online @ www.goodpointmedicine.com and in office.

​Missed Appointment/Late Cancellations: Broken appointments represent a cost to us, to you and to other patients who could have been seen in the time set aside for you. Cancellations are allowed up until 24 hours before the scheduled appointment. We reserve the right to charge $45 for missed or late-canceled appointments. Excessive abuse of appointments may result in discharge from the practice, in which case, you will be provided with other options for continuation of your care.

​If medical insurance information is received at the time of service, as a courtesy, a claim will be submitted to your insurance. Insurance co-payments and annual deductibles not met for the year are payable when services are rendered. Any services that are not covered by your insurance is your responsibility and will be due and payable upon receipt of a billing statement. Should your insurance carrier deny your claim you give us the right to appeal your claim on your behalf. If the correct insurance information or referral is not presented at the time of service, your responsible for the full amount of the charges incurred.

If you do not have medical insurance, financial arrangements must be made prior to services rendered. Otherwise, full payment will be expected at the time of services.

​If account should become delinquent, and is forwarded to our collection agency and/or attorney, the collection agency or attorney fee will be added to the balance due.

I AM CERTIFYING THAT I HAVE READ AND UNDERSTAND THIS OFFICE PROCEDURE / FINANCIAL POLICY AND AGREE TO BE BOUND BY ITS TERMS. I CLEARLY UNDERSTAND THAT ALL SERVICES RENDERED ARE CHARGED TO ME AND I AM RESPONSIBLE FOR ANY UNPAID BALANCE.