Financial Services Agreement

Office Policy

“Bills” (receipts with diagnostic and treatment codes) for submission to your insurance company.  Based on the terms of your policy, you will be reimbursed directly by your insurance carrier for your treatments. If your insurance company requests copies of records and treatment notes, there will be a fee for preparation and copy charges.

In cases of personal injury claims that are not covered by “med pay” insurance, this office asks that you pay for your current treatment.  We do not accept third party liens. The insurance company of the party at fault at the conclusion of your claim will reimburse you. If you have “med pay” coverage from your auto insurance policy, we will bill this for you.

We accept MasterCard, Visa, Discover, American Express, debit, personal checks, and cash for payments on account. If there are any additional charges incurred by our office (NSF checks etc.), they will be added to your account and are payable upon receipt.


Please note that you will be charged for any/all missed appointments without 24 hours prior notification.

We do understand that sometimes emergencies arise and that you may need to cancel your appointment. We ask that you give us at least 24 hours’ notice when you wish to cancel or reschedule an appointment, as this allows us to schedule someone else for that time.  Your account will be charged for missed appointments without sufficient notice.   We will adhere strictly to this policy.

If you have any questions regarding our policy please feel free to contact us.