My Diet MDs Financial Policy
Given below is our billing requirements and financial policy.
"My Diet MDs", is an affiliate of "Sky Fall Medical Services P.C."
a New York State corporation.
"My Diet MDs" recognizes that certain
financial situations can interfere with your willingness or ability to seek
"My Diet MDs" fees are based on a sliding fee schedule (A sliding fee schedule
means that fees are determined based on your (or your family's) yearly income
and number of dependents.
This sliding schedule ensures that you are not
charged more than your financial situation permits and are scaled according to
your family income and number of dependents.
Should extenuating circumstances arise,
we are able to work around your needs; fees can be adjusted on a case-by-case
Please be advised that " My Diet MDs" , its affiliate corporations and all physicians are "OUT OF NETWORK" providers. This means that we do not work directly with any insurance carriers, medicate, Medicare or any unions health plan.
"My Diet MDs" charges a fee of $50.00 per "ITEMIZED BILL " for each visit services.
"My Diet MDs" accept cash, Bank checks, postal money orders, credit or
debit cards for its fee and other charges.
"My Diet MDs" holds a right to charge $100.00 if the appointments are not cancellation at least 30 hours in advance.
All payment for services
are due at the time services are rendered, unless prior arrangements have been made.
Patients are responsible for all collection charges including attorney fees in case the account is referred
to an agency or an attorney for collections.
My fee for each visit is $_________ Plus the cost of (vitamins, supplements,
foods and Tests etc)
My fee for _____ weeks of program is $
_________ including the cost of certain vitamins, supplements payable As ________ initial deposit and
balance in __________ equal installments.
I understand that if my weight management involves medications I will
abide by the state and federal regulations and take medications exactly as
I know that for effective weight management, I need to continue my
treatment/counseling for the number of weeks first stated.
I also understand
that my fee starts from today and is for continuous next number of weeks and I
cannot pick and chose my days and weeks.
I further understand that my
treatment is front loaded (lot is done in first two weeks) and will be
responsible for entire fee even if I fail or elect not to receive any further
services at any time.
Other special terms
I have read and understand all of the above and have agreed
to these statements.
Patient’s Signature Date