Non-Sufficient Funds checks written:  A $25.00 fee will be added to your balance for any check returned.

Collection procedures: Our office engages in all reasonable methods to contact patients about balances owed, including monthly statements with past due and final notices, regular updating procedures, written documentation and phone calls. In the event there is no way to contact you about your balance, we have no choice but to turn your account to collections. It is imperative that you keep your records updated with us if you move or change phone numbers (see Update Forms).

Payment options: If you need to make payment arrangements, please call our office and ask to speak to our Billing Specialist. You are required to stay current on your monthly payments. Use the form for faxing if you are paying by a credit card.  We accept Visa, Master and Discover Card. At present we do not have online payment option.
 

You can get this form as .pdf  file by clicking here....  Fax to:   (512) 440-0299 We accept Visa, Mastercard and Discover cards . Your credit card information will be destroyed after we process this payment. I authorize Dr. Poonawala to charge to my credit card below and apply the payment to my account #____________________________________________: Name:__________________________________________________________ Type of Credit Card: ____Visa ___Mastercard ____Discover Name as it appears on the card_________________________________________ 3- on the back of your card:_____________ Card Number____________________________Expiration Date___________ Your Signature_________________________________Date_____________   _______Yes, please mail me a receipt to address: ______________________________________________________________ ______________________________________________________________ _____No need to mail me a receipt.