PLEASE READ CAREFULLY THE FOLLOWING PARAGRAPHS:

I consent to treatment for the above named patient.

I acknowledge full financial responsibility for services rendered by Melanie Conway, M.D., and authorize transfer of all unpaid amounts to my Visa/MC.

I understand that the payment of charges incurred is due at the time of service. New patient appointments are 350 dollars and follow-ups are 110 dollars. 

I understand that Melanie Conway, M.D. is a non-participating provider-that is, a physician non-affiliated with a commercial insurance plan or government plan (Medicare/Medicaid). I also understand that it is my responsibility to contact the insurance company in order to determine my out of network benefits and if required, obtain precertification prior to seeing the doctor, and I assume full responsibility for any financial loss resulted from denial of non-authorized or non-covered services.

I understand that Dr. Conway does not bill insurance on my behalf, but a receipt for services will be presented to me at the time of service so I may bill my insurance company personally.

CANCELLATIONS AND MISSED APPOINTMENTS POLICY:

Please be advised that a charge equal to the fee for the session will be assessed for appointments cancelled without 24 hours notice or missed appointments.

By filling in the name on this form, you are certifying that you are financially responsible for any and all charges relating to the treatment of the patient.

Thank you for entering your information. Dr. Conway will contact you within 48 hours of submission. You will be redirected to our homepage after hitting the submit button. Please have a nice day.