(323) 851-7876

6711 Forest Lawn Drive

Arlene Gillo Acupuncture 2019

PATIENT FORM

Bill to Insurance?

OFFICE POLICY:

 

Our office Policy has been established to assure that the best health service can be provided to you and your family.

 

Payment is due when services are rendered. You may pay by check, cash or Visa and Mastercard. The doctor’s services are rendered to you not to your insurance company. If you have insurance, we will do our best to determine what dollar amount you are responsible for via telephone verification. We will submit and process your insurance claims and accept the partial payment until insurance payments are received. Some insurance companies send payments directly to the patient and in this case, we ask that you pay for services in full at the time of service. Please keep in mind the amount quoted over telephone may or may not be accurate and you are ultimately responsible for payment for services rendered. We offer a cash discount to patients who pay at the time of service or prepay for a treatment plan. No discount will be given to patients we must bill. All patients will be expected to pay in full for all services until your deductible has been met. If a payment schedule is necessary, arrangements must be made with the doctor providing service, prior to treatment. This will avoid any misunderstanding and enable you to keep your account in good standing. All accounts over 60 days past due will be subject to a monthly billing charge. There is a sir-charge on all returned checks.

 

For cancelation of appointments, we require that 24-hours notice is given. On less than 24-hours notice, you will be subject to a $60.00 late cancellation fee. For patients 15-30 minutes late you may be asked to re-schedule your appointment or have a shortened session.

 

I, the undersigned, agree to be solely and severally responsible for payment of all services rendered to myself and/or any family member. I certify that I have read and understand completely the office policy set forth and I agree to its stipulations. Checking the box below is my consent to be examined and treated and if this office is submitting claims for insurance benefits, that these benefits are assigned to my doctor for the services that he/she provides.

I have read and agree to the terms of this agreement
COMPREHENSIVE ACUPUNCTURE EXAMINATION
                                 
                                   NOTE: This is a confidential record of your medical history and will be kept in this office.
                                 Information contained here will not be released to any person without your authorization.