On the next screen you will have an opportunity to review our group’s payment policy. First we would like to confirm if you are the client and the financially responsible party for your visits. Sometimes, clients, particularly our younger members, ask their parents to be financially responsible for out of pocket expenses including co-pays, co-insurance, deductibles and late cancellation fees or no show fees.
If you are BOTH the client and the financially responsible party please select YES in the form below.
If you are the client and SOMEONE ELSE is the financially responsible party please select NO.
If you are both the client and the financially responsible party, after you sign the payment policy you will receive a copy of the payment policy. If someone else is the financially responsible party, they will have an opportunity to review and sign the payment policy only after you sign the form first. After the other person signs the payment policy, both you and the other person will receive a copy of the payment policy.
We will not be able to move forward and schedule an appointment for you until the payment policy has been signed by the financially responsible party.
Additionally, all clients will promptly be emailed a copy of our Notice of Privacy Practices after the payment policy has been signed. Many thanks for your cooperation!