FEES FOR 2023 Due to decreasing reimbursement from health insurance our practice will be charging for all services not covered by your insurance company.  It is the patient’s responsibility to understand what services are covered by your insurance company.  (Please refer to your benefits manual or call the member service number on the back of your insurance care.)  Thank you for your understanding.

 

PATIENT SERVICES

(not covered by insurance)

Missed appointment fee          $50 (without 24 hour notice)

Missed Appt for Physical        $100 (without 24 hr notice)

Copy of Medical Records         $24 (1-25 pages)

Copy of Medical Records         $31 (26-50 pages)

Copy of Medical Records         $.31 per page
                                (in excess of 50 pages)

Refill without Appointment      $25

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COMPLETION OF FORMS

Disability                      $25/$50 over 10 pages

Insurance                       $25/$50 over 10 pages

Workers Comp                    $25/$50 over 10 pages

FMLA, Medial LOA, Soc. Security $25/$50 over 10 pages

Any Form with Duplicate Information $15

Medicare Supply Form            $15/$25

School From (any kind)          $20

Immunization Forms Outside the Visit  $25

Physician Clearance for Exercise      $25

Adoption Forms                  $50

Dictated Letter                 $50

Handicap Parking Form           $20

All Other Forms (medication, pre-auth, etc.) $10

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