Patient Financial Policy

Time of Service Payments

  • Co-pays, co-insurance and deductibles
  • Any balances past 30 days
  • Self pay patients. Services such as labs and diagnostic test are not included in this charge.



  • We participate with many insurance companies and bill them as a service to you. You are responsible if any insurance company declines to pay or makes you, the policy holder, responsible for a portion of the services.
  • To avoid unanticipated cost, check with your insurance plan to determine if our practice/provider is part of your insurance network.
  • If you have an HMO policy, your insurance may require you to be seen by your Primary Care Provider (PCP). Please obtain the proper authorization and/or referral prior to your visit. Any claim not paid for this reason will be your responsibility.
  • If your current insurance information is not available at time of service, payment in full is due for services prior to being rendered.
  • If the correct insurance information is not given at the time of service, you will be responsible for balance of claims.
  • In the event a health insurance plan determines a service/item is ‘not covered’, you will be responsible for the complete charge.


Preauthorization and Referrals

  • If your insurance plan requires notification that you will be treated by our office, it is your responsibility to obtain preauthorization and/or referrals. Any claim not paid for this reason will be your responsibility.


Return Check Fee

  • Check payments returned for any reason or closed account will be assessed a return check fee of $30.00.
  • This fee will be due in full prior to additional services being rendered.


Statement and Payment Timeline

  • Billing cycle runs once per month. Upon receiving your statement, payment is due in full within 10 days.
  • Any outstanding balance will be assessed $5.00 per billing cycle.
  • If a balance is not paid in full by the third billing cycle, you will receive one phone call and a final demand letter. Your relationship with this office will be dissolved.
  • Should collection proceedings or other legal action become necessary to collect an overdue account, you understand DMA has the right to disclose to an outside collection agency all relevant personal and account information necessary to collect payment of services rendered.
  • You are responsible for all costs of the collection, including but not limited to attorney fees and court costs.


Completion of Paperwork

  • Completion of documents charges reflect Tenn Code Ann 63-2-102:
    • $20.00 for medical records 5 pages or less
    • $0.50 per page for each page copied after the first 5 pages
    • Actual cost of mailing


No Show Fee

  • If you are unable to make your scheduled appointment, please notify our office at least 48 hours prior to your appointment.
  • Notifications made fewer than 48 hours will be subject to a $25.00 cancellation fee.
  • Cancellation fee payments are due in accordance to our normal billing cycle.
  • If you have an excessive amount of no shows, you may be discharged from our practice.


This practice reserves the rights, with or without notice, to change, add to or delete any of the policies, terms, conditions and language presented in this policy.