Register with Dr. Lifestyle
1501 Westcliff Drive Suite 201 Newport Beach Ca, 92660
fax: (949) 289-9612
Thank you for choosing our services for your needs. Please read and sign the agreement below. It lays out billing, scheduling and cancellation procedures. If you have any questions please ask for clarification.
- Payment of all fees is expected at the time of service or via credit card on file. We will NOT assist you in submitting claims to your insurance carrier but we can help you submit to https://reimbursify.com/individual-page/. The best way to get reimbursement is to download the reimbursify app and submit superbills within 1 month of your visit and not to wait till the year ends.
- It is the client’s responsibility to check insurance benefits and coverage. You will be responsible for any non-covered services, deductibles, co-payments or co-insurances, as determined by your insurance carrier. Accounts unpaid by the insurance carrier greater than 90 days will be billed to the client.
- I hereby authorize payment of medical benefits directly to Dr. Melissa Mondala / Dr. Micah Yu for all services rendered where applicable.
- Out-of-pocket payments can be made via credit/debit card, cash or check and are due on the date of your appointment. Credit/debit card payments can be made directly with your Health Provider. Please make checks payable to Dr. Lifestyle. There is a $35 fee for all returned checks.
- I hereby authorize Dr. Lifestyle to release to government agencies, insurance carriers and all others who are financially liable for my care, all information to substantiate payments for my care and to permit representatives thereof to examine and make copies of all records related to such care and treatment. I understand that if at any point my insurance coverage changes, I am to notify administrative staff prior to my next visit. Failure to do so will result in being personally and completely responsible for the full amount of all services.
- I will be responsible to pay a $100 late cancellation fee for any missed or canceled initial visits, not made at least 48 hours in advance prior to the scheduled appointment time.
- I will agree to pay a deposit of $100 prior to the visit and understand if an appointment is cancelled within 48 hours or if I do not show up, then the $100 deposit will be forfeited and another $100 will have to be deposited for another reschedule. I understand that the $100 deposit will be applied to the balance of my visit if I show up to my appointment.
- If I default on my account, I understand I will be subject to finance and/or legal fees in addition to the total account balance.