Patient Information

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • WORKERS COMP. ONLY. PLEASE LIST THE FOLLOWING:
  • INITIAL VISIT: $RATE

    ALL FOLLOW-UPS: $RATE

    NOTE: MANY INS. CARRIERS NOW REQUEST BILLING BY PROCEDURE CODE EACH CODE: $RATE

    ALL PATIENTS ARE PERSONALLY RESPONSIBLE FOR FULL PAYMENT OF ALL CHARGES INCLUDING INSURANCE COMPANY DENIALS, DEDUCTIBLES AND COPAYMENT FEES. CANCELLATIONS SHOULD BE MADE 24 HOURS IN ADVANCE.

    NOTICE OF ADVICE: THE TREATMENT MAY NOT BE COVERED BY THE PATIENT’S HEALTH CARE PLAN OR INSURER WITHOUT A REFERRAL AND THAT SUCH TREATMENT MAY BE A COVERED EXPENSE IF RENDERED PURSUANT TO A REFERRAL

  • Date Format: MM slash DD slash YYYY