As a courtesy we will bill your primary insurance carrier if you provide ALL necessary
information (such as insurance cards with their CORRECT billing address and REFERRALS).
Co-pays are collected for each visit at the time of service.
Statement of Financial Responsibility
I understand my insurance carrier may not approve or reimburse my medical services in full due
to usual and customary rates, benefit exclusions, coverage limits, lack of authorization, or
medical necessity. I understand I am responsible for fees not paid in full, co-payments, and
policy deductibles and co-insurance.