Insurance
Insurance is a contract between you and your insurance company. We will bill your primary insurance company as a courtesy to you. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility. You agree to pay any portion of the charges not covered by insurance. If your insurance company requires a referral and/or preauthorization, you are responsible for obtaining it. Failure to obtain the referral and/or the preauthorization may result in a lower payment from the insurance company.

Past Due Accounts
If your account becomes past due, we will take necessary steps to collect this debt. If we have to refer your account to a collection agency, you agree to pay all of the collection costs incurred. If we have to refer collection of the balance to an attorney, you agree to pay all attorney's fees which we incur plus all court costs. In case of suit, you agree the venue shall be in Montgomery County, Maryland.

Returned Checks
There will be a $30.00 handling fee for any and all returned checks.

Waiver of Confidentiality
You understand if this account is submitted to an attorney or collection agency, if we have to litigate in court, or if your past due status is reported to a credit agency, the fact that you received treatment at our office may become a matter of public record.

Transferring Records
You will need to request in writing and pay a $25.00 copying fee to have your records sent to another doctor. You authorize us to include all relevant information, including your payment history.

Missed Appointments
There will be no charge for rescheduling an appointment, provided a 24-hour notice is given. Patients who do not show up for an appointment or cancel with less than 24 hours notice will be charged $25.00. This fee must be paid before a new appointment is scheduled. Please remember that once an appointment is made, it has been reserved specifically for you.

Effective Date
Once you have signed this agreement, you agree to all the terms and conditions contained herein and the agreement will be in full force and in effect.