Please complete your Patient Registration Form AND BRING OR SUBMIT:
1) valid I.D.,
2) insurance card and
3) a credit card, to be kept on file.
**We will charge your credit card the (insurance) contracted amount, if insurance does not pay, due to deductible, copays, incorrect insurance info and/or non covered services. **
***FOR TELE HEALTH APPTS:***
LOOK FOR AN INVOICE FROM SQUARE FOR YOUR COPAY. IT WILL BE EMAILED TO THE EMAIL ADDRESS THAT YOU USED TO BOOK YOUR APPT. THIS MUST BE PAID PRIOR TO YOUR APPT. FAILURE TO DO SO MAY CAUSE YOUR APPT TO BE CANCELLED AND RESCHEDULED.**
THE INVOICE WILL COME FROM SQUARE, SO CHECK YOUR SPAM FOLDER TOO.
Thanks for your cooperation!