OUR OFFICE IS DEDICATED TO PROVIDING THE BEST POSSIBLE CARE & SERVICE TO YOU. WE REGARD YOUR UNDERSTANDING OF OUR FINANCIAL POLICIES AS AN ESSENTIAL ELEMENT OF YOUR CARE. AS A COURTESY, OUR OFFICE WILL BILL YOUR INSURANCE COMPANY FOR SERVICES PROVIDED TO YOU. IF YOUR INSURANCE COMPANY DOES NOT REIMBURSE OUR OFFICE WITHIN A REASONABLE AMOUNT OF TIME (TWO MONTHS IS CONSIDERED THE MAXIMUM PROCESSING PERIOD), YOU WILL BE BILLED FOR THE VISIT(S). IF AT A LATER DATE WE RECEIVE PAYMENT FROM YOUR INSURER, WE WILL REFUND ANY OVERPAYMENT DIRECTLY TO YOU.

IF YOUR INSURANCE COMPANY REQUIRES COPAYMENTS FOR OFFICE VISITS, THAT PAYMENT IS DUE AT THE TIME OF YOUR VISIT. IF OUR OFFICE HAS TO BILL YOU FOR THAT COPAYMENT, PLEASE BE ADVISED THAT THERE WILL BE A $3.00 BILLING FEE ATTACHED TO EACH PATIENT BILL SENT.

IF YOUR INSURANCE REQUIRES REFERRALS FOR SPECIALIST VISITS, IT IS YOUR RESPONSIBILITY TO OBTAIN THAT REFERRAL PRIOR TO YOUR VISIT WITH DR. GLAZIER. IF THE REFERRAL IS NOT ON FILE AT THE TIME OF THE VISIT, WE WOULD HAVE TO RESCHEDULE YOUR VISIT

NOT ALL SERVICES PERFORMED BY DR. GLAZIER ARE GUARANTEED TO BE COVERED BY YOUR INSURANCE COMPANY. IT IS YOUR RESPONSIBILITY TO VERIFY COVERAGE FOR SERVICES EXPECTED TO BE PERFORMED BY YOUR DOCTORS. IN THE EVENT THAT A CHARGE IS REJECTED BY YOUR INSURANCE, YOU WILL BE RESPONSIBLE FOR PAYMENT OF THAT CHARGE. ALSO, IF YOUR INSURANCE DOES NOT COVER 100% OF OUR CHARGES, YOU ARE RESPONSIBLE FOR ANY BALANCE DUE. IF YOU HAVE ANY QUESTIONS REGARDING YOUR BILL, PLEASE CALL OUR OFFICE AND ASK FOR ANJI.

IF OUR OFFICE HAS TO SEND ANY PATIENT DUE BALANCES ON YOUR ACCOUNT TO OUR ATTORNEY FOR COLLECTION, YOU WILL BE RESPONSIBLE FOR ALL COLLECTION COSTS AND ACTUAL ATTORNEY FEES.

YOUR SIGNATURE IS REQUIRED TO VERIFY THAT YOU HAVE READ AND UNDERSTAND THE ABOVE POLICIES.

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PATIENT NAME (PLEASE PRINT)

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SIGNATUREDATE

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IF PATIENT IS UNDER 18, LEGAL GUARDIAN MUST SIGN HERE.
PLEASE STATE RELATIONSHIP TO PATIENT.