South Coast Neurology

Patient Registration Form

Please fill out ALL Fields

Our staff is trained to inform you of the financial policies of this office.

• Payment is due at the time of service. If payment is not paid at time of service, a $10 billing fee will be applied
• Appointments for regular care that are not canceled at least 48 hours before the scheduled appointment during hours of operations are subject to a $40 “NO SHOW FEE”.
• We accept payment in the form of cash, check and credit card (*).
• I understand that I am financially responsible for all charges for services to me, including the balance remaining after payment of possible insurance benefits or non-payment.
• In the event it is necessary to refer your account to an attorney for collections, you will be responsible for all charges accrued; i.e. attorney’s fees, court costs, expenses, etc.

* Check Writing Policy: No check will be honored without driver’s license. All returned checks are subjected to a return check fee of $40.

* CHARGEBACK CARD: Any card that a chargeback is initiated without the consent of South Coast Neurology, Inc is subject to a $40.00 fee, regardless of the balance as well as late fees that apply to an overdue balance. Primary Insurance and Plan Insurance Address should not be required to sign

I am aware that obtaining test results may require a face-to-face consult with a licensed medical professional. Some test results cannot be given over the phone,
email and/or via facsimile. These regulations are in compliance with appropriate medical care guidelines and other government agencies within the of State of California. Initials