Financial Policy Agreement
Please read the following policy carefully and complete the agreement form below. This form is required for all new patients.
Fee-for-Service Practice
Convergence Medical Center is a fee-for-service practice. Payment in full is due at the time of service. We accept cash, check, and all major credit cards, as well as HSA and FSA cards. We do not bill insurance directly; however, we are happy to provide a detailed superbill that you may submit to your insurance company for potential reimbursement.
Service Fees
Payment Policy
- Payment is due in full at the time of service.
- We accept cash, check, all major credit cards, HSA, and FSA.
- A superbill will be provided upon request for insurance reimbursement purposes.
- Balances not paid at the time of service may be subject to a billing fee.
- Returned checks are subject to a $35 returned check fee.
Cancellation Policy
We require a minimum of 24 hours notice for appointment cancellations or rescheduling. This allows us to offer your appointment time to another patient in need.
- Cancellations with less than 24 hours notice may be subject to a $50 late cancellation fee.
- No-shows (missed appointments without notice) will be charged the full visit fee.
- Repeated late cancellations or no-shows may result in discharge from the practice.
Refund Policy
Fees paid for completed services are non-refundable. If you have concerns about a charge, please contact our office within 30 days of the service date and we will work to resolve the matter promptly.
If you have any questions about our financial policies, please contact our office before your appointment. We are committed to transparent communication about all aspects of your care.
Sign the Agreement
By completing and submitting this form, you acknowledge that you have read, understood, and agree to the financial policies of Convergence Medical Center.