Cynthia J. Moorman, M.D., P.A.
Patient Name: Date of Birth:
We are committed to providing our patients with the best possible medical care. This policy has been
established to avoid any misunderstanding or disagreement concerning payment for profession services.
It is your responsibility to:
• Bring your insurance card(s) at every visit.
• Be prepared to pay your Deductible, Coinsurance, and/or Copay at each visit. Payment can be
made by cask, check or credit card. We accept Visa and MasterCard. There will be a $25.00
charge for all returned checks.
• Bring any required insurance referrals for treatment at the time of your appointment. If you
do not have the referral, your appointment may be rescheduled, or you will be financially
responsible for all charges incurred.
• Non-participating insurances: If we do not participate with your insurance, you will be
responsible for payment in full at the time of each visit. We will file a claim to your insurance
company as a courtesy. Your claim will process at your out-of-network benefit level.
• Patients with no medical insurance coverage: If you have no active medical insurance coverage,
you will be expected to pay for services in full at the time of each visit.
• It is ultimately your responsibility to know your individual coverage limitation. If you have
questions about your insurance, we are happy to help you. However, specific coverage issues
should be directed to your insurance company member service department.
• Please give the office 24 hours notice if you are unable to keep your appointment. A $40.00
fee may be charged for missed appointment without 24 hour notification. Patients missing
appointments that require a sign language interpreting service will also be responsible for the
service charge of the interpreter. Please help us serve you and all of our patients better by
keeping scheduled appointments.
• Completing insurance forms, medical leave, disability forms, copying of medical records, etc.
requires office staff time and time away from patient care for our doctor. We require pre-
payment for these services which are determined by the length and complexity of the form or
letter and the prep and the number of pages copied of the medical record.
• If your account is placed in the hands of collection agency and/or attorney for collection, you
will be responsible to pay for any unpaid balance and all collection and/or attorney fees.
• If the patient is a minor (18 years and younger), the parent or guardian must sign below. The
parent, guardian, or unaccompanied minor is responsible for all above mentioned charges.
Questions about financial arrangements should be directed to the physician’s office. We are
here to help you. Please sign that you have read and agree to this Financial Policy
Signature of Patient (or Responsible Party, if Minor) Date Form Date 06/30/2018
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