Patient Financial Policy

Thank you for choosing Chestnut Ridge Family Medical as your health care provider.  We are committed to building a successful physician-patient relationship with you and your family.  You clear understanding of our Patient Financial Policy is important to our professional relationship.  Please understand that payment for services is a part of that relationship.  Please ask if you have any questions about our fees, our policies, or your responsibilities.  To prevent any billing delays or difficulties, the office must be notified of any patient information changes (i.e. address, name, insurance information, etc.)



Please present a current insurance card at each visit.  All co-payments and past due balances are due at the time of check-out unless previous arrangements have been made with our billing coordinator.  We accept cash, debit, checks, or credit cards.  Absolutely no post-dated checks will be accepted.

Insurance Claims

Insurance is a contract between you and your insurance company.  In most cases, we are NOT a party of this contract.  We will bill your primary insurance company as a courtesy to you. In order to properly bill your insurance company we require that you disclose all insurance information including primary and secondary insurance , as well as, any change of insurance information.  Failure to provide complete insurance may result in patient responsibility for the entire bill.  Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility and benefits. If your insurance company is not contracted with us, you agree to pay any portion of the charges not covered by insurance, including but not limited to those charges above the usual and customary allowance.  If we are out of network for your insurance company and your insurance pays you directly, you are responsible for payment and agree to forward the payment to us immediately.

Self-pay Accounts

Self-pay accounts are patients without insurance coverage, or patients covered by insurance plans in which the office does not participate.  Self-pay patients will be required to pay a $75.00 payment at the time of each visit. Payment arrangements will be made for any balance.

Missed Appointments

Chestnut Ridge Family Medical requires 24 hours cancellation notice prior to your scheduled appointment.  Failure to provide adequate notice will result in a $25.00 cancellation fee.

Returned Checks

The charge for a returned check is $25.00 payable by cash or money order.  This will be applied to your account in addition to the insufficient funds amount.  You may be placed on a cash only basis following any returned check.


The parent(s) or guardians(s) is responsible for full payment and will receive the billing statements.  A signed release to treat may be required for unaccompanied minors.

Outstanding Balance Policy

It is our office policy that all past due accounts be sent two statements. If payment is not made on this account, a single phone call will be made to try to make payment arrangements.  If no resolution can be made, the account will be sent to the collection agency, or attorney, and possible discharge from the practice.  Regardless of any personal arrangements that a patient might have outside of our office, if you are over 18 years of age and receiving treatment, you are ultimately responsible for payment of the service.  Our office will not bill any other personal party.

This financial policy helps the office provide quality care to our valued patients.  If you have any questions or need clarification of any of the above policies, please feel free to contract us.  We can be reached at 716-260-1593.

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