We are dedicated to addressing your healthcare needs and simplifying your insurance and financial arrangements as much as possible. To achieve this efficiently for all our patients, we ask that you adhere to our financial policy. By signing below, you agree to the following terms:

1. I am ultimately responsible for paying for the services I receive from this practice, even those covered by my insurance. This practice will submit claims for reimbursement to my insurance provider as a convenience, but the payment responsibility remains mine.

2. Immediate payment may be required at the time of service, including co-pays and additional payments if it is determined that my visit will not be fully reimbursed by my insurance, often due to an unsatisfied deductible.

3. This practice may deny service or charge a service fee if I fail to pay a co-pay at the time of service.

4. I am responsible for providing my current address, phone number, email address, and insurance information at each visit.

5. I agree to provide this practice and/or its designated payment agent with my debit/credit card or ACH information.

6. I understand that my signature and payment information will be stored digitally for future use by the practice. The payment card or ACH information will be truncated and "tokenized" by the payment agent to ensure security. Information may be obtained through a card swipe, manual entry, void check, or verbally in person or over the phone.

7. If necessary, this practice may offer an automated payment plan for my share of costs, which may incur interest. I can avoid interest charges by paying my bill immediately or by the due date.

8. I authorize this practice and/or its designated payment agent to charge my payment card and/or ACH account for all amounts owed for medical visits, procedures, or supplies, including amounts agreed upon as part of a payment plan, co-payments, coinsurance (after insurance proceeds), amounts not covered by insurance, and fees for missed appointments or late cancellations.

9. If a patient balance is not satisfied by a charge to my payment method or payment plan, I may receive a monthly statement for any outstanding balance, which I must pay by its due date to avoid interest.

10. Transaction receipts will be kept in my patient file or emailed to me if I provide a valid email address.

11. I authorize this practice and/or its designated provider to send electronic account statements and invoices to my email address on file. It is my responsibility to maintain a current email address, as I will not receive mailed copies of electronic statements.

This authorization remains in effect until I provide written notice of cancellation to the practice. Authorization for services already rendered cannot be canceled or refunded. I agree to notify the practice in writing of any changes to my payment or other information.