Agreement of Financial Responsibility

Thank you for choosing us as your health care provider. We are committed to providing quality care and service to all of our patients. The following is a statement of our financial policy, which we require that you read and agree to prior to any treatment.

  • Please understand that payment of your bill is considered part of your treatment. Fees are payable when services are rendered. We accept cash, check, credit cards, and pre-approved insurance for which we are a contracted provider.
  • We will attempt to confirm your insurance coverage prior to your treatment. It is your responsibility to provide current and accurate insurance information, including any updates or changes in coverage. Should you fail to provide this information, you will be financially responsible.
  • It is your responsibility to know your own insurance benefits however, including whether we are a contracted provider with your insurance company, your covered benefits and any exclusions in your insurance policy, and any pre-authorization requirements of your insurance company.
  • If we have a contract with your insurance company we will bill your insurance company first, less any copayment(s) or deductible(s), and then bill you for any amount determined to be your responsibility or denied by your insurance payor. This process generally takes 30-45 days from the time the claim is received by the insurance company.
  • If any payment is made directly to you for services billed by us, you agree to promptly submit same to Our clinic until your patient account is paid in full.
  • If we do not contract with your insurance company, you will be expected to pay for all services rendered before your visit. We will provide you with a statement that you can submit to your insurance company for reimbursement.
  • Proof of payment and photo ID are required for all patients. We will ask to make a copy of your ID and insurance card for our records. Providing a copy of your insurance card does not confirm that your coverage is effective or that the services rendered will be covered by your insurance company.
  • Please understand some insurance coverages have Out-of-Network benefits that have co-insurance charges, higher co-payments and limited annual benefits. If you receive services are part of an Out-of-Network benefit, your portion of financial responsibility may be higher than the In- Network rate.

Charges for Health Coaching Services 

We are excited to have you participate in our health coaching program provided by inHealth Medical Service, Inc. Our contracted dietitians, nutritionists and clinical staff are dedicated to your health and to providing care that exceeds your expectations. As stated above, should your insurance deny any of the preventative services provided by our contracted staff, you will responsible for payment.

Below is an example of charges you would be held responsible for should your insurance deny coverage.

Monthly follow-up visit RD/Health Coach (1)              $65.00 –  $90.00

Weekly visits (3)                                                                  $40.00 –  $65.00

Total:                                                                                $185.00 –  $225.00


“No Show” Policy

Definition of a “No-Show” Appointment

We define a “No-show” appointment as any scheduled appointment in which the patient either:

– Does not arrive to the appointment

– Cancels with less than 24 hours’ notice

– Arrives more than 10 minutes late and is consequently unable to be seen

Impact of a “No-Show” Appointment

“No-show” appointments have a significant negative impact on our business and the healthcare we provide to our patients. When a patient “no-shows” a scheduled appointment it:

– Potentially jeopardizes the health of the “no-showing” patient

– Is unfair to other patients that would have taken the appointment slot

– Disrespects the provider’s time

To Avoid Getting a “No-Show”

  1. Confirm your appointment
  2. Arrive 5-10 minutes early
  3. Give 24 hours’ notice to cancel appointment

Consequences of “No-Show” Appointments

1st no-show – Letter/Email sent to patient reminding them of the policy

2nd no-show – Letter/Email sent and patient billed appropriately (see below)

  • $25.00 per 15 min. (weekly visit) appointment slot
  • $40.00 per 30 min. (monthly visit) appointment slot

3rd no-show – Site termination