This form is not submitted online. Please print and sign and return to the office.
Candida Fink MD
12 Parcot Ave New Rochelle NY 10801
Phone 877-534-1090 Fax 914- 560-2106
www.finkshrink.com
FINANCIAL POLICIES & PROCEDURES
Insurance
· I do not participate in any health insurance plans
· I will provide an invoice that can be submitted for reimbursement
· Please check with your insurer to determine out of network reimbursement
· Telephone visits are not usually reimbursed by insurers
· Some insurers reimburse for video appointments
Payment
· Payment is due at time of service
· We accept cash, checks and all major credit cards
We ask that you keep a credit card on file
Cancellations and Missed Appointments
Please read carefully and sign below:
- The office requires at least 24 hours notice of cancellations
- Late cancellations and missed appointments are billed for the full office visit
Initial:__________________ Date:_________
Unpaid Bills
- Bills that are more than 30 days past due begin to accrue interest at a rate of 1.6% per month.
- If the bill is 90 days overdue, we will request that you make a payment plan
- Bills that are over 180 days past due may result in termination of services.