Missed Appointments. We require a 24 hour cancellation notice. If you miss your appointment or do not cancel with the required notice, additional fees may apply: Office Visit $75, Second Missed Office Visit $100, New Patient Visit $100.

Self-Pay Patients. Full payment is expected at the time of service for all visits.

Address Change. It is important that we have your correct address information on file. Please advise us any time there is a change to your address, telephone or other contact information.

Out-of-Network. As a general rule Dr. Pazmiño is out of network with all insurance plans, and the following applies: If you request it, our billing company MedNet will be able to contact you and quote for you an estimated fee before services/procedures are performed. After your appointment we will submit a claim to your plan for services performed. You are ultimately responsible for all professional fees regardless of your insurance coverage status. Once insurance has processed your claim you will receive a monthly bill indicating an outstanding balance on your account. Depending on your plan, payment may be sent to you; if you receive this payment you agree to forward this check or reimburse Dr. Pazmiño/SpineCal immediately. Before your appointment please be sure that you understand that the Doctor is out-of-network and you will be billed for the costs of the care. We will help you find out if you have out-of-network benefits and we will submit a claim to your plan on your behalf. Please let us know at any time if you do not want us to submit a claim on your behalf.

Co-Payments / Co-Insurance / Deductibles. You are expected to pay your co-payment and any co-insurance and/or deductibles at the time of your visit.

Non-Medical Fees. Additional fees may apply to: returned checks; completion of Disability, FMLA and other forms. As a rule we do not complete EDD Disability paperwork — this is expected to be completed by your internist or family physician. Payment is due at the time services are provided or upon receipt of a statement from our billing office. We accept cash, check, money order, or credit card (Visa, Mastercard, Discover). Returned checks are subject to a fee. We do not accept traveler’s checks.

Payment Plans. We understand that medical care can become expensive. If you have concerns about your ability to pay, you can contact us for help in managing your account.

Failure to Pay. If you do not pay your bill, your account will be sent to an outside collection agency. If your account is sent to a collection agency you will need to contact them directly to settle your account balances.

Policy and Fee Changes. The policies and fees are subject to change.

Acknowledgement. I have read and understand these Financial Policies and I agree to be bound by their terms in making payment for medical services provided to me by SpineCal and Orthopaedic Institute and Dr. Pazmiño. I hereby authorize payment to be made directly to the physician for services provided to me. I understand that I am financially obligated for charges not covered by this authorization. I authorize the release of my information to physician, provider or third-party payor (insurance company) in order to process payment.