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903A South Greeley Highway, Cheyenne, WY 82007
INSURANCE AGREEMENT Please read the following as it has important information regarding your account with us. Our clinic participates with:
Please note, our office is not a TRICARE participant. If your insurance company is not listed above, please call us to make sure we accept payment from your insurance. The submission of claims is a courtesy to you. It is your responsibility to have your current insurance card with you at time of service. You are responsible for deductibles that are not yet met, co-payments, cost shares and/or denied benefits. If you do not have insurance, you are responsible for payment at time of service. There will be no exceptions. For your convenience we do accept money orders, cashiers checks, personal checks (these can be post-dated – ask for details), Visa, MasterCard, Discover, debit cards and, as always, cash. As with any insurance, there are “usual and customary” fees. This is the amount that your insurance allows for office visits, procedures, etc… Please understand this is an agreement between your insurance and yourself when you enrolled with their company. In most cases, the doctor’s fees are above the “usual and customary” rate which insurance companies choose to pay. Our office cannot and will not allow the insurance company to set the amount that we charge for services. If you have any questions, please feel free to contact one of our Billing Specialists.
Patient Signature: __________________________________ Date: __________
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