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Payment and No-Show Policy *

Atembis LLC requires payment of copay at time of visit, outstanding balances are due immediately, and no show fee for failure to show or cancel within 24 hours of a visit ($100 for medical, $120 for behavioral visits) for all new and existing patients. There are other fees not inclusive to your visit for paperwork completion. Pricing is typically $30-$60. As a courtesy, Atembis LLC, verifies your benefits with your insurance company. A quote of benefits is not a guarantee of benefits or payment. Your claim will process according to your plan, if your claim processes differently from the benefits we were quoted, the insurance company will side with the plan and will not honor the benefit quote we received. It is the policy of Atembis LLC that payment is due at the time of service unless other financial arrangements are made in advance. We require all patients to pay their deductible, copay and/or coinsurance payment at the beginning of each visit. At the conclusion of your visits with us you may be billed for any outstanding balances. If there is a credit, you will be provided a refund promptly. If you are covered by health insurance with Family Medicine or Primary Care benefits, we will be happy to bill your insurance. Please provide your insurance information to the front office staff and we will verify your coverage as a courtesy. Accepting your insurance does not place all financial responsibilities onto this practice, and you will be held accountable for any unpaid balances by your plan. Although we are contracted with some insurance carriers, our services may not be covered by your particular insurance plan. Please remember that you are 100 percent responsible for all charges incurred: our verification of your insurance benefits are not a guarantee of payment. We highly recommend you also contact your insurance carrier and check into your coverage for Primary Care. Do not assume that you will not owe anything if you have more than one insurance policy. Currently, our pricing ranges below: Evaluation and Management: $45.00 - $283.00 Preventive (wellness) Services: $118.00 - $223.00 Vaccine administration fee: $16.00 - $40.00 Vaccines: Varies based on product, please inquire In-office procedures: Varies based on procedure, please inquire if needed By checking below, I understand and agree to this policy.

I agree to the Payment and No-Show policy

I affirm by my clicking this box that I have reviewed and agree to the Notice of Privacy Practices. I also agree to the use of my cell phone for communications. We do not send advertisements by text. *

I affirm that I have reviewed the Notice of Privacy Practices. I also agree to the use of my cell phone for communications with your office. My text will not be used for advertisements and my information will not be sold or used by third parties.

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Medication Agreement *

We here at Atembis LLC are actively involved in reducing the epidemic of prescription drug abuse in our community. It is for this reason that it is important that all new patients understand that 1) we do NOT write any regular prescriptions of opiates for new patients, 2) that we discourage the dependence on all schedule drugs (including medications such as Ambien, Xanax, etc) and will require seeking ways to help patients with their issues without the use of narcotic medications, and 3) we will screen all patients using the Arizona Controlled Substances Prescription Monitoring Program. By clicking below, you agree and understand our office policies regarding narcotic medications, and provide us consent to review the CSPMP database along with your Pharmacy Benefits Manager database.

I understand the office policies regarding schedule medications, and agree to the above requirements.