Skip to main content
Home » Contact Us » Patient Forms » Out of Network Policy

Out of Network Policy

  • As a courtesy to our patients, we are happy to file the paperwork for plans for which we are out of network. Because we do not have a contractual agreement with these plans, we have no guarantee that they will pay for services, how much they will pay, or if they will pay in a timely manner. Consequently, it is still the patient’s responsibility to pay for care at the time of service.If we receive any payment from the plan, we will promptly reimburse you (typically within 3 business days). We encourage you to contact your plan with any questions that you have regarding out of network benefits.

  • MM slash DD slash YYYY
  • (By signing, I acknowledge that I have read and agree with the above policy, I understand that my plan may pay a reduced amount, or may not pay for out of network services, and I agree to pay for services at the time they are rendered.)