OFFICE POLICY ON PAYMENT TO SERVICES RENDERED
Our office requests payment of your portion of the services rendered on the day that they are
rendered. We confirm with your insurance company that the services rendered are covered and
what portion that they will pay. By collecting payment from you it brings the cost down on sending
statements, and cuts your cost down by not having to write a check, put a stamp on the envelope
and sending it in. As well as cost of services not raising due to cost of equipment, and products used
in this process. However we do have our occasional stubborn insurance companies, which for
whatever the reason, may not cover as much as we expected. We will then send you a statement for
that balance. There are also the occasional insurance companies who pay more than what we
expect and we will reimburse you for your funds or just apply them to your account for future use,
whichever you prefer. You can request which ever it is that you prefer. Thank you for your
cooperation with this change.
If you choose not to pay on the day services are rendered, we can send you a statement for your
remaining balance. However there may be a small fee incurred to cover the cost of the statement. If
for some reason you are not able to make this payment in full within a five-month period, we will
need to refer your account to our collection agency. This may include any collection fees charged,
including but not limited to reasonable attorney fees, by us or by the agency. Again thank you for
your understanding.
Please sign and date below if you understand and accept these circumstances.
___________________________________________________ Date ________________
Patient or Parent’s Signature