Payment Agreement

Your health insurance policy is a contract between you and your insurance company. It is important that you understand its provisions. Your insurance company can usually best answer your questions. Please make a point to know your insurance benefits. It is your responsibility to know your insurance company’s procedures and coverage. If you are not certain of your benefits, please contact the benefits coordinator at your (or your spouse’s) employer for clarification.

In order to secure your appointment, I require that I have a credit card on file for all clients. This credit card will not be billed unless you choose to use your credit card as the form of payment (see below), or in the case of a missed appointment without the agreed upon 24-hour cancellation policy.

Forms of Payment:

I accept the following forms of payment: Cash, Check, Visa, MasterCard, and Discover. This is expected on date of service.

Please complete the form below, or print and fill out the PDF Payment Agreement, and bring it to your first appointment.