If you are unable to keep your appointment, kindly give 24 hours notice. Cancellation with less than 24 hours notice will result in a $75 CHARGE.
I, the undersigned, certify that I (or my dependent) have insurance coverage with the above plan(s) and assign directly to Thomas Pavlovic, MD and Christopher Pavlovic, MD all insurance benefits if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by my insurance.
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I hereby authorize Thomas Pavlovic, MD and Christopher Pavlovic, MD to release all information necessary to secure the payments of benefits. I authorize the use of this digital signature on all insurance submissions.
