FULL PAYMENT IS DUE AT THE TIME OF SERVICE. I ACCEPT CASH, CHECKS, OR CREDIT CARDS.
Thank you for choosing us as your health care provider. We are committed to the success of treatment. The following is a statement of our financial policy which we require you read and sign prior to any treatment. All patients must complete the Personal Information Form and Alternate Payers must sign this financial policy before the first appointment.
I understand and agree that I am responsible for the cost of the above patient’s treatment with Dr. Leifer. Dr. Leifer’s billing service can provide the patient with a completed HICFA (standard insurance company billing form) that may be submitted to their insurance company for direct reimbursement, however Dr. Leifer provides no guarantee that the insurance company will provide any reimbursement for services. I also agree that if it becomes necessary to forward this account to a collection agency that, in addition to the amount owed, I will be responsible for reasonable cost of collection, including attorney’s fees. I understand that I will be charged for all appointments not cancelled 72 hours (three business days) in advance by the patient and all exceptions to this must be negotiated with our office.
This agreement remains in effect during the course of the patient’s treatment with this office and may be revoked in writing. Please notify us of changes to your card information such as new expiration dates or other updates. Charges will appear on your card statement from Apex Treatment Services. Please contact us with any questions you may have regarding payment for treatment. We require that patients with an alternate payer maintain a limited release of information on file for you so that we may discuss financial matters associated with this treatment and we welcome your input.