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Billing Information
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Bill Insurance (Credit Card for Balance)
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Self Pay (Credit Card)
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Self Pay (Cash or Check)
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I understand co-pays, self pay and balances are due at the time of service.
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I agree to a $25 charge for services not covered by insurance. (Laser, Dry Needling, etc)
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We prefer a card on file. Receipt of charges emailed and statements available online.
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Permission to bill this card for co-pay, co-insurance, self pay and other balance due?
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Name on Card
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Credit Card #
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Expiration Date
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CVV
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Zip
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