Center for Fetal Medicine and Women’s Ultrasound

6310 San Vicente Blvd. | Suite 520 | Los Angeles, CA 90047 Tel: 323-857-1982 | Fax: 323-857-5336

ACKNOWLEDGEMENT OF RECEIPT OF
FINANCIAL POLICY and NOTICE OF PRIVACY PRACTICES

Your signature below will acknowledge that you have read and/or received copies of both the Center for Fetal Medicine and Women’s Ultrasound Financial Policy and Notice of Privacy Practices. In addition, I hereby authorize Center for Fetal Medicine and Women’s Ultrasound to bill my insurance company and receive payment from them on my behalf. I acknowledge, however, that I am responsible for payment of my account and any and all charges associated with its collection.

In the event any balance is not paid as agreed within 60 days of the billing date on the first statement, the undersigned agrees to pay a collection fee equal to 30% of unpaid balance.

I acknowledge receipt of this Insurance Information/Financial Policy and will abide by these requirements.
If you have any questions, please call us at (323) 857-1952.We appreciate your cooperation on this very important matter.

 

Center for Fetal Medicine

Our Location

6310 San Vicente Blvd,
Suite 520
Los Angeles, CA 90048

Call Us: 323-857-1952
Fax Us: 323-857-5336
Records sent to [email protected]
Monday-Friday: 8:00am – 4:00pm

2001 Santa Monica Blvd,
Suite 870W
Santa Monica, CA 90404

Call Us: 323-857-1952
Fax Us: 323-857-5336
Records sent to [email protected]
Monday-Friday: 8:00am – 4:00pm

6310 San Vicente Blvd, Suite 520 Los Angeles, CA 90048 | 323.857.1952


Important insurance information!

Please be sure to visit our Patient Information page prior to your visit!

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