Operating Hours: Mon – Fri: 8:00AM – 5:00PM | Sat – Sun: Closed
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Consent to Treatment

I consent to and authorize the performance of any treatments, examinations, medications, anesthesia, medical services and surgical and diagnostic procedures as deemed necessary by my medical provider and practice employees under direct supervision of my medical provider. The practice of medicine is not an exact science. No guarantees have been made to me as to the result of any treatment or examination in the Practice. The healthcare professional participating in my care will rely on my medical history and other information obtained from me, my family or others having knowledge about me, in determining whether to perform or recommend the procedures; therefore, I agree to provide accurate and complete information about my medical history and conditions.

I consent to testing and disposition of specimens, devices, and foreign objects. If tissue specimens include products of conception or fetal remains, they may be disposed of by the lab after examination or retained for scientific purposes.

Health Information Disclosure

State and federal law requires us to maintain the privacy of your health information and to inform you about our privacy practices. Our office will promptly notify affected individuals in the event of a breach of their PHI. We will keep health information confidential, using it only for the following purposes: Treatment, insurance and payment services, if requested by law, if abuse or neglect is suspected, public health, and in an emergency to facilitate care.

We limit various staff members’ access to your health information according to their primary job functions. The practice may download medication history from pharmacies, health plans, and other healthcare providers. This may include information about medications prescribed for mental health conditions, sexually transmitted diseases, substance abuse disorders, and HIV/AIDS.

I understand that unless I request confidentiality, privacy laws allow the practice to communicate with family members or others who may be involved in my care. If I do not want this, I will notify my provider and ask my family to leave when the provider is discussing care with me. You can access your chart and if you want to modify your information, please notify us in writing.

Financial Policy

Payment of your bill is part of your healthcare. Please provide your insurance information so that we can bill accurately. If your insurance company does not pay, the balance will be transferred to you. It is your responsibility to contact your insurance carrier to confirm that our office participates in your plan and if a referral is necessary. We want to emphasize that as your physician our relationship is with you, not your insurance company. We file the insurance claim as a courtesy to our patients, but all charges are your responsibility from the date rendered. All deductible, coinsurance, and copays are due at time of service.

Checks returned for non-sufficient funds will be charged a $36.00 administrative fee, in addition to the patient balance. A $25.00 administrative fee is charged for forms and letters completed by our office. Copies of records need at least 2 weeks to complete and we charge an administrative fee for this based on the number of pages.

If you are unable to keep your scheduled appointment, please notify our office 24 hours in advance. Failure to do so will result in a $25.00 no-show charge. After 3 no-shows, you will be dismissed from the practice. There is a $100 cancellation fee for scheduled surgeries that are cancelled less than 48 hours in advance. If a patient’s balance is turned over to a collection agency, an additional 30% of the balance will be added to the account. All unpaid balances will accrue a 5% late charge if not paid in full after 90 days or not set up on an acceptable payment plan. All unpaid balances will be sent to collections after 90 days.

Patient Rights

Patient Responsibilities