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Consent for Treatment and Billing


I consent to evaluation and treatment via telehealth by the doctors and staff at Pacific Family Medicine, LLP (PFM). I hereby authorize release of medical information that is necessary for my further treatment. I authorize release of information, including treatment and protected health information to my insurance company that is needed to process payment for services. I authorize my insurance carrier to pay benefits for services rendered, directly to PFM. I understand payment is expected at the time services are rendered and that I am responsible for any balance.

Payment Policy

Co-pays are due at the time of service, or full payment is due for self-pay patients. We accept cash, checks, or credit cards (Visa and MasterCard). There is a $35 service charge on any returned check; payment in full will be required within 10 days of returned check notice.


Our office will kindly bill your insurance company as a courteous to you. We participate with a number of medical insurance plans that we will contact to verify eligibility and benefits. Please realize that you have the ultimate responsibility of verifying the coverage with your insurance. You acknowledge that we may be an out of network provider with your insurance. You will be responsible for any balance not paid or denied by your insurance carrier. Patients who do not supply accurate insurance information will be considered self-pay. This includes accurate coordination of benefits between multiple insurance carriers.

Insurance Referrals

Our office will assist with obtaining referrals for treatment whenever possible if your plan requires a referral from your Primary Care provider. However, it is your responsibility as the patient to verify referral is in place before seeking treatment. If a claim is denied due to a lack of referral you will be responsible for charges.

Missed Appointments

If you are unable to keep your appointment you must notify the office at least 24 hours prior to your scheduled appointment as courtesy to the doctors, staff and other patients. If you cancel or no-show without sufficient notice, you will be billed a $100 no-show fee payable by you, not your insurance company.


Please inform our office of any changes in your address, insurance, or next-of-kin information.

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