Payment Policies
    The Chicago Pain Clinics do everything possible to minimize the cost of medical care. You
    can help a great deal by eliminating the need for us to bill you. The following is summary of
    our payment policy.

    All payment is expected at the time of service.
    Payment is required at the time services are rendered unless other arrangements have been
    made in advance. This includes applicable co-insurance and co-payments for participating
    insurance companies. The Doctors Pain Clinic accepts cash, personal checks. There is a 30 $
    service charge for returned checks.

    Outstanding Balance
    Patients with an outstanding balance of 60 days overdue must make arrangements for
    payment prior to scheduling appointments. We realize that people have financial difficulty.
    Please communicate with our billing and collection staff so that they may assist to create a

    Insurance
    We bill participating insurance companies as a courtesy to you. You are expected to pay
    your deductibles and co-payments at the time of service. If we have not received payment
    from your insurance company, you will be expected to pay the balance in full. You are
    responsible for all charges.


    Refunds
    Over payments will be refunded upon written request to the responsible party within 30
    days of our office confirmation.

    Missed Appointments /Untimely Cancellations
    Missed appointments represent a cost to us, to you and to other patients who could have
    been seen in the time set aside for you. If you are unable to keep your appointment, please
    give 24-hours notice to avoid charge. We reserve the right to charge for missed or untimely
    canceled appointments. Excessive abuse of scheduled appointments may result in discharge
    from the practice.

CHICAGO PAIN CLINICS L.L.C
Phone# 708-344-1234
FAX # 800-525-1686