Financial Policy

Patient Financial Policy

Effective Date: [Insert Date, e.g., January 1, 2026]

Thank you for choosing our practice for your healthcare needs. We are committed to providing high-quality, personalized care in a transparent and efficient manner. To help maintain this standard of service, we have established the following financial policy. By receiving services, you acknowledge and agree to these terms.

1. Payment Responsibility

You are ultimately responsible for the full cost of all services provided, including consultations, lab work, lab analysis, treatment plans, and any related fees.
Payment is due at the time services are rendered unless prior arrangements have been approved in writing.
For insured patients: We do not bill insurance directly for most services (please confirm with our office if any exceptions apply). You are responsible for knowing your insurance benefits and any out-of-network reimbursement options.

2. Package Deals for Lab Work, Lab Analysis, Consultation, and Treatment Plans

We offer discounted package pricing when the full amount for the bundled services (lab work, lab analysis, consultation, and treatment plan) is paid in full in advance (prior to ordering labs or scheduling the consultation).
The discounted package rate reflects the efficiency and commitment of completing the full program upfront.
Partial payments do not qualify for the discounted package rate. If only a partial payment is made, services will be charged at our standard (non-discounted) individual rates for each component.

3. Accepted Payment Methods

We accept the following forms of payment:

HSA/FSA
Cash
Personal check (subject to verification; returned checks may incur a fee)
Major credit/debit cards
Venmo
Apple Pay
Bitcoin (please confirm current acceptance and any processing fees with staff at the time of payment)

We do not accept post-dated checks or deferred payments without a signed agreement.

4. Payment Arrangements and Partial Payments

In limited circumstances, we may approve a payment plan with a substantial upfront deposit and a signed written agreement outlining remaining balances, due dates, and consequences of default.
Any approved payment plan does not qualify for package discounts unless full payment is received prior to service delivery.
For lab orders: Labs will generally not be ordered until the full lab portion (or full package amount, if bundled) is paid, to avoid incurring unreimbursed costs on our end.
We reserve the right to place a credit card on file for automatic or future charges with your authorization.

5. Consequences of Non-Payment

Balances not paid at the time of service or per an approved agreement may result in:
- Withholding of non-emergency services (including future lab orders, consultations, or treatment plans) until the account is brought current.
- Late fees or interest on overdue balances (as allowed by law).
- Referral to a third-party collections agency after reasonable attempts to resolve the balance.
You agree that, in the event of collections, you are responsible for all associated costs, including collection fees, court costs, and reasonable attorney fees (to the extent permitted by law).
Repeated non-payment may lead to termination of the patient-provider relationship following proper notice, in accordance with ethical and legal guidelines.

6. Additional Notes

We strive to provide cost estimates when possible, but final charges depend on the specific services rendered.
No-shShows or late cancellations (less than 24 hours notice) may incur fees.
We encourage open discussion about financial concerns. If cost is a barrier, please speak with our staff about available options, such as phased testing or external resources (note: we do not offer sliding-scale fees or charity care at this time unless otherwise noted).

By signing below (or by receiving services), you acknowledge that you have read, understood, and agree to this Financial Policy. A copy will be provided upon request.

Patient Name (Printed): _______________________________

Signature: _______________________________ Date: _______________

Guardian/Responsible Party (if applicable): _______________________________