Billing & Insurance

Financial Policy

Thank you for choosing us as your health care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our Financial Policy. We require you to read and sign this policy before any treatment can be rendered. 

Missed Appointment:

We reserve the right to charge a fee of $50 for all missed appointments that are not cancelled with a 24-hour advance notice. This fee will be billed to the patient. This fee is not covered by insurance and must be paid prior to your next appointment. Multiple missed appointments or cancellations in any 12-month period may result in discharge from the practice.  


We reserve the right to charge a fee of $200 for a surgery that is cancelled by patient within 1 week of scheduled surgery. A fee of $50 will be charged to the patient each time the surgery is rescheduled upon the patients request. If patient misses surgery without notice, we reserve the right to charge a fee of $1,500. These fees are not billable to insurance or reimbursable and must be paid before we can schedule any further appointments or surgeries. If you are requesting a refund of your surgery deposit, you will receive your refund less any applicable fees.    

Regarding HMO's, PPO's and Managed Care Programs:

We do not participate in some of these programs. Please check with your insurance company to see if we are providers of your plan. It is your responsibility to obtain initial referral forms, etc. required by your particular insurance company, this also includes follow-up visits and visits to other physicians in our group. Please be aware that if you are seen out of network, you are liable for the difference in coverage benefits. Also, some HMO/PPO/ Managed Care Primary Care Physicians require all x-rays be taken at their office only, check with your physician before your appointment.


You will be expected to pay your copay prior to seeing your physician. If you are unable to pay, you will be required to reschedule your appointment.

Regarding Patients With No Insurance:

Payment is due at time of service.

Regarding Medicare:

All of our providers are participating physicians with Medicare. We will file all charges (including x-rays, braces, and etc.) with your Medicare and your supplemental insurance, if applicable. If you do not have a supplemental insurance, you will only be billed for the 20% not paid by Medicare or any deductible that has not been met.

Completion of Forms (Disability, FMLA, Physician Statements, Etc.):

A charge will be assessed per form. Prepayment is required before the form(s) will be completed.

Regarding Workmen's Compensation/Auto/Liability:

Our office requires authorization prior to initial visit. If authorization is not received, our office will call on the initial visit and try to obtain it. If we cannot obtain authorization, we will ask for your health insurance information. Also, you will be responsible for all fees until the case has been settled. WE DO NOT BILL ATTORNEYS IN WORK COMP, AUTO, AND/OR LIABILITY CASES.

Minor Patients:

If you are a minor your parents and/or guardian need to accompany you to our office before treatment can be rendered. You need to make arrangements prior to being seen with your parent and/or guardian for payment to be made at the time of treatment.


For your convenience we do have x-ray facilities in the building. If x-rays are indicated in your treatment, charg­es are handled in the same manner as the physician charges. If you have had x-rays taken somewhere else, please bring them with you to your appointment.


In the event we need to have a lab drawn, our office uses an outside laboratory services. You will receive a separate bill for the lab services.

Payment For Service:

All patients must complete a patient information form and provide insurance information, if appropriate, or make payment arrangements prior to leaving the clinic.

  • Payment in full. Payment in full is expected and can be made by cash, check, or credit card. 
  • Payment Plan. If you are unable to pay the account in full, financial arrangements will be established based on the following guidelines. When establishing a payment plan, the patient (or their guarantor) will sign a contract agreement with the 1st payment due upon signing the contract. This approach requires a minimum payment of $25.00. The contract will specify the dollar amount of subsequent payments and the day of the month the payments will be made. When you set up a payment plan, you will continue to receive a monthly statement. If you miss one (1) payment and fail to bring the account current by the due date of the following payment, the account will be referred to the clinic’s collection agency.
    • Patient Due Balances of $500 or less will be set up on a 90 day payment plan
    • Patient Due Balances of $501 - $1000 will be set up on a 180 day payment plan
    • Patient Due Balances of $1000+ will be set up on a 1 year payment plan

Uniform Application of Policy:

This policy will apply to all patients, employees, or others who present themselves for services [at anytime, including any future visits].

It is always your responsibility to see that your account is paid, regardless of insurance or any other circumstances (such as litigation). Patient is responsible for costs associated with collecting said owed balances including but not limited to, collection agency fees, attorney fees, and court costs. 


Questions about your statement?
Please call toll-free at (888) 397-7362.

Questions about our Financial Policy?
Please call our financial counselor at (316) 295-2621.