Financial Policy

This statement is to inform you of our policy. We are committed to providing you with the highest quality of medical care using only the best materials and technology available today. Our financial policy is intended to facilitate excellent service to you while minimizing our administrative cost. It is the responsibility of the patient to obtain a valid referral from their primary care physician by their contract with their insurance company. All patients that do not have a referral at the time of the visit will be accepting financial responsibility if one is not obtained or may need to reschedule the appointment until a valid referral is on file. All copayments are due at the time of service. All commercial and uncontracted plans will be billed by this practice for one thirty day period as a courtesy. Any partial or unpaid balances after the thirty day period are the responsibility of the patient and are due upon receipt of the first statement. WE must emphasize that as your medical care provider, our relationship with you, NOT your insurance company. Uninsured “self” patients will be asked to make an initial deposit of $200.00 at time services are rendered. Pricing and payment options can be arranged with our billing department. This practice is not responsible for any non covered services provided and /or performed by outside laboratories or facilities. Our staff will attempt to use participating facilities; however, this is not always possible. Therefore, any billing related issues are directly between the patient and facility. Today and all subsequent visits will be billed to your insurance company. Patients or responsible party signing below is responsible for all deductibles and all copayments for all visits.

Signature/Date

Appointment No Show Policy We require at least 48 hours notice to cancel or reschedule any diagnostic testing taking place at Plymouth Ears, Nose and Throat or there will be a “No Show Fee” of $50.00 billed to the responsible party. This includes but is not limited to AVE, Allergy Testing, PH/Manometry, Fee and Strobe and Ultrasounds.

Signature/Date

Financial Policy

now offering Same day appointments

30 Aldrin Road, Plymouth MA 508-746-8977

1 County Road, Bourne MA 508-746-8977

104 Park Street, Hyannis MA 508-746-8977

544 Main Street, Weymouth MA 508-746-8977