Financial Responsibility & Cancellation Policies

Patient Acknowledgement of Financial Responsibility & Cancellation Policies Cancellation/No Show Policies

When you book your appointment, you are holding a space on the calendar that is no longer available to our other patients who need an appointment. Out of respect to our physicians and patients, we have the following cancellation policy:

1. If cancellation is necessary, we require that you contact our office at least 24 hours in advance for office visits and 72 hours in advance for surgical appointments and diagnostic testing
2. Office Appointments will be charged a fee of $75. Surgical/Procedure Appointments/Diagnostic Testing (Ultrasounds) will be charged a fee of $175
3. A “no show” or missed appointment without notification will be assessed fees as below
4. Below fees are not billable to your insurance company and will be patient’s responsibility
5. If you are 15 or more minutes late for your appointment, the appointment may be canceled & rescheduled
6. Repeated missed appointment may result in the termination of the physician/patient relationship

Financial Responsibility Policies

1. Co-Pays and Deductibles: You must pay your Copay and Deductible at the time of service as required by your insurance company.
2. Discounts: Cash discounts will be given for patients without insurance if you pay in full for services on the day of the visit: 10% (ten percent) if paid by cash.
3. No Insurance/Self Pay: If you do not have health insurance or proof of coverage, we require a $75 deposit before your first visit. These deposits will be applied to your medical bill.
4. Payments on Account Balances (Copays/Deductibles): You are responsible for the timely payment of your account at the time of your visit.
5. I agree to allow Manhattan Specialty Care to charge my credit card on file or any amount not covered by insurance for all services related to my appointment visits including no show or cancellation fees that may apply
6. My credit card will be stored by Global Payments/Healow Pay which are secure credit card processors affiliated with Manhattan Specialty Care to collect payments. Bills and Receipts can be furnished upon request

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