Our Office Policies
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  • Consent for Treatment: I hereby authorize consent to examination and treatment of the patient by the WPG provider and clinical staff, and to performance of any procedure that is deemed necessary.

  • Authorization to Release Information: I hereby authorize WPG to release personal or medical information of the patient, to my insurance company(s) or worker’s compensation carrier necessary to process claims, to other physicians when necessary to assist in the treatment or care of the patient as well as when required by the law. 

  • Insurance: I acknowledge that it is my responsibility to be familiar with my particular insurance plan. The provider will be making medical recommendations based on my health needs and not on insurance reimbursement. I understand that I am responsible for verifying that WPG or its physicians are participating with my insurance plan prior to receiving services. If my insurance plan requires pre-authorization for any services or referrals, I am responsible for ensuring that the services have been pre-approved by my insurance plan. I authorize and request my insurance company(s) to make payment of any medical benefits directly to the physician or WPG. 

  • Financial Responsibility: I understand that I am responsible for payment at the time services are rendered including previous balances, copayments, coinsurance, deductibles, or services not covered by my insurance plan. I acknowledge that I have provided current and accurate insurance information to enable timely reimbursement for medical services. If insurance information cannot be verified or if I do not have health insurance coverage, I will pay in full at the time of service by credit card, cash, or check. If I do not present my insurance card at each visit, I will be responsible for payment in full for services rendered. I understand that any balance after my insurance company has paid is due within 30 days of receipt of the billing statement. I understand that accounts not paid after 90 days from the date of service will be turned over to a collection agency and reported to the credit bureau.

  • Payment: All payments will be collected at the time of your office visit. If your insurance is based on a copay payment plan our office will collect the specialist copay amount. If your insurance is based on a deductible plan, and if the deductible has not been met, our office will collect a fee, which is $225 currently. This fee is subject to change in the future. 

  • Cancellation Policy: I understand that if I cannot keep a scheduled appointment, I must notify the office at least 24 hours in advance of the appointment time. I am aware that if I do not provide 24 hours notification before cancellation or do not show up for a scheduled appointment. The cancellation fee is subject to change in the future.

  • Testing (labs, radiology imaging, procedures, and other investigations): I understand that an outside laboratory, radiology department, or other facilities will be used for investigations. These facilities may process blood, urine, or tissue specimens as ordered by the physician. These services will be billed separately by respective facilities. It is my responsibility to contact the lab or these facilities with any questions regarding the cost of the investigations, or if you have any questions regarding their bill.

  • Minor Patients: I understand that as the adult accompanying the minor, I am responsible for any payment amount due for services rendered regardless of the responsible party or insurance policyholder. I will be provided with a receipt for my personal reimbursement.

  • Doctor-patient relationship: I understand that a healthy and trustworthy relationship between doctor and patient is necessary for good patient care. If at any point during the care, this relationship becomes unhealthy, both, the doctor and patient, are encouraged to communicate so with each other. As such, it will be acceptable for both to terminate this relationship, and seek patient care elsewhere. 

  • Not Allowed: I understand that no audio or video recording is allowed during the visit. Smoking/vaping, use of recreational substances/alcohol, and weapons are prohibited in the clinic.

  • Email communication: Getting parent/patient feedback is essential for good patient care. I acknowledge that my email address might be used for getting feedback or reviews regarding your experience (such as Google Reviews).


I have read and understood and I agree to adhere to the above-mentioned policies. The notice of privacy practices can be provided upon request at the time of the clinic visit.