Financial Policy

Patient Financial Agreement

Sayana Medical & Wellness Center is committed to serving our patients with care and professionalism, and from our patients we expect the same commitment from our patients. This includes being on time for your appointment AND calling and/or texting to cancel an appointment if you can’t make it or if you are running late for your scheduled time. Sayana Medical patients also have financial responsibilities, including presenting your identification and insurance cards at every appointment AND making your copay and deductible payments at the time of your office visit (using cash or credit card). PLEASE NOTE: No checks are accepted.

Your responsibility is to provide us with accurate and complete information concerning your primary and secondary insurance medical benefits, including referral documents from other providers. Current identification and insurance benefit cards are to be presented at each office visit. As a courtesy, Sayana Medical & Wellness Center will file your insurance claim for you if your insurance is accepted. If you are a Medicare patient, we will bill Medicare and your secondary insurance for you.

For services outside of our clinic, like Blood work, radiology, laboratory, surgery centers, physical therapy, hospitals and rehabilitation centers, it is YOUR responsibility to know which facility you are required to use and your benefits. If you aren’t sure, please talk to your insurance member services or one of our staff before scheduling.

My signature below authorizes that payments be make for my claims, the release of medical information necessary to pay my claim, and/or the release of benefits payable and medical information necessary to pay any secondary insurance payer.

I have read and I understand Sayana Medical & Wellness Center financial policies and I accept responsibility for the payment of any fees associated with my care.

MM slash DD slash YYYY
Patient Name(Required)

Financial Policy will be submitted to Sayana Medical Spa and Wellness Center