I have read the provided policy regarding my financial responsibility to Medical Health Associates, for providing wellness and medical services.  I certify that the information I provided is, to the best of my knowledge is current, true and accurate.  I authorize my health plan to pay any benefits directly to Medical Health Associates the full and entire amount of bill incurred.  As applicable, I agree to pay any amount due after payment has been made by my health plan. 

Co-Pay Policy

I understand I am responsible for paying my copay upon arrival at each visit.

High Deductible Plan

I understand that with a high deductible health plan, Medical Health Associates will expect a payment at time of service of no less than a minimum of $70.00 or perhaps more depending on the services being rendered.  Medical Health Associates will submit the claim and bill me for any remaining balance.

Self-Pay, Non-Participating, No Fault Insurance and Workers’ Compensation

I understand that as self-pay, no fault or having a health plan with which Medical Health Associates does not participate that I will be responsible for all medical services rendered at Medical Health Associates.  I agree to pay Medical Health Associates for the full amount of charges related to the office visit and any treatment/procedure rendered at each visit.  Medical Health Associates will provide an itemized receipt for the services reflecting the payment made.

Missed Appointment Policy

I understand that fee for missing an appointment fee is $50.00 per occurrence.