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© 2013 Created by V is for Vodka Designs

HIPAA Notice of Privacy Practices

Disclosure of Fees

- Insufficient Funds (Returned Check) Fee:              $35


- "No-Show" Fees:                                                      $75 +

In order to sustain our practice for the benefit of all of our patients, appointments MUST be canceled more than 24 hours in advance of the appointment time so another patient can fill that slot. No shows, cancellations, and appointments rescheduled less than 24 hours in advance of the scheduled time are charged a cancellation fee of $75. Please note that there will be an additional charge of $25 in addition to the $75 for each subsequent missed appointment. In order to ensure that your cancellation or reschedule request is received, please submit your cancellation or reschedule request via our website contact form at, or by emailing If you choose to call to cancel or reschedule, please document the date, time, and staff member to whom you speak so that we can verify your call through our call logs. 


- Printed Lab Results:                                                $5

Lab results are accessible through your patient portal at no charge. Viewing lab results on your portal is convenient and easy. However, if you wish for us to provide you with a printed copy of your results, there is a $5 fee. If other physicians you are seeing require copies of your lab results, we can electronically send the results to other physicians at no charge. 


- Prescription Refills:                                                 $25

This fee applies to prescriptions called in, in lieu of an office visit, or in the event a prescription has already been processed and sent to the pharmacy & you request a change of pharmacy or ask that it be processed through another insurance plan than the one listed in your medical chart, or if extra quantities of a prescription is requested. Fees vary based on the number of prescriptions requested for processing. ALL refill requests called in or requested through the patient portal are subject to a $25 fee. You may call your pharmacy to request your refill and avoid this fee. If there is a problem with filling your prescription, the pharmacy will contact us.       


- Statement Fee:                                                          $10

Payment is due at the time of service. Statements are only sent by our office once a claim has been filed to insurance and there is a patient balance owed after the claim is processed. If you ask that we mail you a statement rather than paying at the time of service, a $10 administrative fee will be added to your account. 

- Form Completion:                                                    $25 - $100

This fee applies if you have forms needing completed that cannot be completed during an office visit, or are not applicable to the office visit during which you request the form to be completed. Examples of documents that cannot be completed during an office visit:  FMLA paperwork, Disability paperwork, etc.    

- After Hours Calls:                                                     $50

This fee applies to non-emergency after hours calls to the on-call healthcare provider, and is strictly at the discretion of the provider. If prescriptions are called in, the fee will be charged. 


- Medical Records:                                                      $25 +
If you request a set of paper medical records for your own use or to be transferred by mail to another physician, the fee is $25 for the first 20 pages, and .50 cents a page thereafter. Expedited requests are an additional $25. Records can be sent to another physician electronically at no charge. If you wish to supply a flash drive, up to 500 pages of records can be transferred to the drive for a fee of $25.  These fees were established as fair and acceptable by the Texas Medical Board. 

- Collection Fees:                                                        $35 +      

This fee applies if your account goes 30 days or more past due. If arrangements to pay have not been made within that time period, a certified letter will be sent to you requesting payment, and a fee of $35 fee will be added to the past due balance at that time. Additional fees will accrue if the balance remains unpaid, and may include fees from a collection agency if the account goes past 90 days.