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​​Thank you for choosing Denton Heart Group, PA as your health care provider. We are committed to providing excellent health care services to you, our patient. As a part of your professional relationship, it is important that you have an understanding of our financial policy.

All patients must read and sign this form prior to receiving services.

It is your responsibility to provide us with your most current insurance information.

Notification of any change in your insurance status must be provided 24 hours before your scheduled appointment.

If you fail to provide accurate insurance information in a timely manner, your insurance company may deny the claim.  If the claim is denied, you will be financially responsible for services rendered or you risk having to cancel your appointment until the office is able to verify your coverage.

Before receiving services, you must verify that we are participating providers for your insurance company. 

Copayments, coinsurance and/or deductibles are due at the time of service.  We will estimate the amount you owe based on information we receive from your insurance company.  However, you are responsible for paying the full amount determined by your insurance company once they have paid your claim, regardless of our estimation.  For your convenience we accept Visa, Mastercard, Discover, American Express, Cash and Checks. 

In the event you submit payment by check and the bank returns the check unpaid for any reason, we will add $30.00 to your original balance.  In addition, we may seek all additional legal remedies provided to us under Texas law. 

Should an overpayment occur on the deductible or percentage amounts charged, once we are notified by the insurance company, we will apply a credit to your account and a refund check will be issued to you within 30 days of notification.  If you have an appointment within the next 30 days, the credit will be applied to your account and can be used at that visit.

Office Hours and Missed Appointments

Regular office hours are 8:00am to 5:00pm, Monday thru Friday. 

We require 24 hours notice if you find it necessary to cancel your appointment.  There may be a $50.00 fee for all appointments not cancelled within 24 hours. 

We do reminder calls as a courtesy only.  If you do not receive a reminder call, you are still responsible for keeping your appointment. 

Prescription Refills

Medications will be handled during regular office hours only. It will be your responsibility to contact your pharmacy to make a request on a refill. The pharmacy will contact our office to obtain authorization to fill your prescription. 

Please allow 48 hours for completion on all refill requests.

Fee Disclosure

1. Medical Records​​​$25.00
2. Returned Checks​$30.00
3. Letters to Employer/School$25.00
4. FMLA/Disability/Insurance paperwork$45.00
5. Missed appointments without 24 hour notice$50.00
6.​ DMV Handicap Sticker Application​​$25.00

Termination of the Physician – Patient Relationship

A good relationship between a physician and his or her patient is essential for quality medical care.  There are times when this relationship is no longer effective and the physician finds it necessary to ask the patient to select another physician.  The following are some of the situations that would make this necessary:

  1. After the third missed appointment
  2. Nonpayment of The patient's account
  3. Not following treatment recommendations
  4. Misuse/abuse ofprescribed medications
  5. Abusive


I have read and understood the above Financial Policy of Denton Heart Group, PA and agree to abide by the terms of the policy.


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              Signature                            Date

Hours of Operation

Monday - Friday

8:00 a.m. - 5:00 p.m