Financial Policy

At Align Family Health, we understand the importance of effective chronic disease management in maintaining your overall health and well-being.

Thank you for choosing Align Family Health & Wellness Center: as your health care provider. Please carefully read and initial each statement and sign below. This policy has been put in place to ensure that financial payments due are recovered to allow us to continue to provide quality health care for our patients. It is important that we work together to assure that payment for services is as simple and straightforward as possible. Our practice manager or billing department will be glad to discuss these policies with you.

  1. I understand that if I do not have my insurance card, and/or copayments, my appointment may be rescheduled until such a time that I can provide the required documents or payments.

  2. I understand that Align Family Health & Wellness Center will collect all copayments at the time of visit and any procedure deductibles and coinsurance up to an amount equal to payment in full for the planned procedure code. Payment in full and expected coinsurance payment responsibility are determined by the anticipated billing code(s), details of your insurance policy, and agreement between your insurance company and Align Family Health & Wellness Center.

    Any overpayment to your account will be refunded to you at your request after payment and/or remittance has been received from your insurance company.

  3. I understand that a $45 service fee will be added for any checks returned for any reason and I will be responsible for payment of this fee and the amount of the returned check. NSF checks must be redeemed with certified funds ( cashier’s check, money order, or cash.)
  4. I understand that if I am unable to make a scheduled appointment, I need to contact Align Family Health & Wellness Center at least 24 hours before my scheduled appointment time. Due to a high demand for appointments, missed appointments prevent us from scheduling appropriately and keep others in need of urgent care from being seen. A $25 FEE WILL BE ASSESSED FOR ALL MISSED APPOINTMENTS NOT CANCELED WITH AT LEAST 24-HOUR ADVANCED NOTICE.
  5. I understand that if my accounts not paid in full within 90 days of the statement date, a 35% collection agency processing fee will be added to the outstanding balance and will be turned over to collections for further processing. No additional appointments will be made for delinquent accounts until they are brought current.
  6. Align Family Health & Wellness Center will allow 60 days from the date of filing for my Insurance Company to process or pay a claim. It is my responsibility to provide my insurance company with requested Information needed to process a claim for services. It is also my responsibility to notify Align Family Health & Wellness Center if there is any change in my insurance coverage, residence, or phone number. ULTIMATELY, IT IS UP TO ME TO


I have read and agree to all the provisions of the above financial policy. I understand that I am ultimately responsible for all professional fees incurred for professional services performed by the clinic provider.


We require insured patients to complete assignment of benefits authorizing insurance to remit payment to primary care office. I hereby assign all medical benefits to include major medical benefits to which I am entitled, private insurance, and any other health plans to: Align Family Health & Wellness Center. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges where or not paid by said insurance. I hereby authorize said assignee to release all medical information necessary to secure the payment.