Patient Name: Date of Birth

Patient Name: Date of Birth: ,

Bala Family Practice

Self Pay Policy

Thank you for choosing our practice! We are committed providing you excellent medical treatment and care. Prompt payment of your bill is one aspect of your responsibility as it pertains to your treatment and care. Bala Family Practice understands that illness or injuries are unplanned and sometimes may occur during difficult economic times. For this reason, Bala Family Practice has a set of reasonable fees. To be seen by our health care provider a $100 consultation fee is due at the time of service. Consultation fees are Non-Refundable and Non-Negotiable.

Labs, X-rays, Sonograms, supplies, medications, and/or procedures are also discounted from the regular charges. Please note, because it is difficult to accurately estimate the exact charges for our services prior to being examined by our health care provider the best estimate is obtained after the evaluation by our health care provider. Before these services are provided, consent and pricing will be obtained before proceeding. All charges are due at the time of service and are Non-Negotiable. In rare instances you may receive an additional bill after your visit if the billing department discovers any of the following after your visit while processing your chart: Omitted supplies or procedures and other circumstances not mentioned herein. We will process a refund if we discover that you were accidentally overcharged for your visit.

I have read the provided policy regarding my financial responsibility as a Self Pay Patient to Bala Family Practice for providing service to the above named patient.

Signature: Date: .