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(317) 844-5656

Serving the Indianapolis area with
excellence in hearing healthcare.

12065 Old Meridian Street
Carmel, IN 46032

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Thank you for placing your confidence in our physicians. We wish to take this opportunity to review our payment policy for services rendered.
Please contact us with any questions or if you are unable to make a timely payment. We have a direct line to a representative who can help you. (317) 844-6403

ALL CO-PAYS are due at the time of your visit. If you are unable to pay your copay at the time of your visit, your appointment will be rescheduled.

THERE WILL BE A $20 FEE for all no shows or appointments not cancelled within 24 hours of your appointment.

DEDUCTIBLES may be collected prior to surgery as indicated by your insurance company.

METHOD OF PAYMENT Cash is best. Checks are accepted, but prepayment for surgeries will delay the surgery until
the check clears the bank. Visa and Mastercard are also accepted, as well as access to a line of credit offered by Care
Credit.

STATEMENTS are sent out on a monthly basis. After 30 days your account is considered delinquent.

DO I NEED A REFERRAL? If you are unsure, contact your insurance carrier. If your company requires a referral and we have not received an authorization prior to your arrival at our office, we will make one attempt to call your primary care physician to obtain it. If we are unable to obtain the referral at that time, your appointment will be rescheduled.

HOSPITAL, X-RAY, LAB, PATHOLOGY, AND ANESTHESIA charges are all billed separately by each facility or provider. We are not responsible for knowing rates or procedures for these bills.

ALL SERVICES WILL BE FILED WITH YOUR INSURANCE PLAN, regardless of whether we are a provider on that plan's provider panel. Please be sure we have complete information so as to avoid delays. Balances not paid or adjusted by the insurance plan will be billed to the responsible party/patient for payment.

HEARING AIDS ARE NOT COVERED BY MANY INSURANCE COMPANIES. Special payment plans can be arranged for the purchase of hearing aids.

IN EVENT OF DEFAULT IN PAYMENT OR IF LEGAL ACTION should become necessary to collect an unpaid balance due for medical services rendered to me or my family, I/we agree to pay attorney fees, collection agency fees and other such costs as the court determines proper.


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