Our Spring location is now open Mon- Fri: 8am-5pm. Walkins Welcome!
  1. PCP For Life
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  3. Registration


    Circle if Preferred Contact Number
    Circle if Preferred Contact Number
    Circle if Preferred Contact Number
    Parent's if Patient is a Minor
    2nd Parent's if Patient is a Minor
    I have insurance coverage as above and assign directly to PCP for Life or N. Karimjee, M.D. all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the clinic to release all information necessary to secure the payment of benefits.
    Patient (Parent OR Legal Guardian if Minor)

    OPTIONAL: (This is used in certain confidential (CLINIC BASED) reporting to Health and Human Services or other Federal Program)
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    Thank you for allowing us to take part in your healthcare. To help manage the cost of your healthcare, we have developed a fair payment policy so that you can receive comprehensive care and minimize the stress associated with the financial burden of good care.

    If you have a past due balance or incur substantial new charges that make it difficult for payment at the time of service the office staff has the capacity to allow you to make a payment plan to address those amounts. We do ask for reasons of fairness, that all patients where this applies make the plan before they incur additional charges. The payment plan requires as little as $10 at a time, but does require that payment is automated. Be assured all private information is managed by a national 3rd party vendor who follows federal privacy regulations.

    If you have insurance, we will bill it for the services we provide, however, please realize, insurance benefits, is a contract between you and/or your employer and your insurance carrier. If there are services within certain standards that we provide, even if the insurance does not pay, they are your responsibility. It is also your responsibility to advise us of any updates or changes to your insurance. Most insurance will not pay if a claim is filed after 60 days and therefore it would be your responsibility.

    Co-Pays are due at the time of service

    We may send periodic statements with any balances after your insurance company has paid. If you have any questions about charges on your statement, please contact the Billing Department immediately. The balance on your account is due immediately once responsibility has been determined, whether, by the EOB (Explanation of Benefits) from your insurance company or by statement.

    Where Does Your Income Fall?

    Where Does Your Income Fall?

    Payment Plan Options

    Past Due Balance BI – Weekly Monthly
    Up to $50 $10 $15
    51-100 $15 $25
    101-150 $20 $35
    151-200 $25 $45
    201-250 $30 $55
    251-300 $35 $65
    301-400 $40 $75
    401-500 $45 $85
    501-600 $50 $95
    601-700 $55 $105
    701-800 $60 $115
    801-900 $65 $125
    901-1000 $70 $135
    1001-1100 $75 $145
    1101-1200 $80 $155
    1201-1300 $85 $165
    1301-1400 $90 $175
    1401-1500 $95 $185
    1501-1600 $100 $195
    1601-1700 $105 $205
    1701-1800 $110 $215
    1801-1900 $115 $225
    1901-2000 $120 $235
    2001-2100 $125 $245
    2101-2200 $130 $255
    2201-2300 $135 $265
    2301-2400 $140 $275
    2401-2500 $145 $285
    2501-2600 $150 $295
    2601-2700 $155 $305
    2701-2800 $160 $315
    2801-2900 $165 $325
    2901-3000 $170 $335



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