Provider Information

Practice Name: Razia Jayman-Aristide, MD PLLC
Provider: Razia Jayman-Aristide, MD
Address: 265 Post Avenue Suite 140, Westbury, NY 11590
Phone: (516) 226-0404
Email: info@oyahealth.life

As part of our professional relationship, it is important that you have a clear understanding of our financial policies. Accordingly, this Payment Agreement must be entered prior to the provision of any services by this practice.

The purpose of this form is to outline patient responsibilities regarding payment, insurance, missed appointments, and more — and includes a signature section for patient acknowledgment and agreement so that the terms of this agreement are binding.

Billing and Insurance

This practice does not accept or bill insurance companies, and you are solely responsible for any and all fees for services provided to you by this practice. All fees must be paid in full at the time of service. However, we do work with Reimbursify to generate invoices that we can submit to your insurance company for reimbursement, provided you download the Reimbursify app, fill in your accurate and complete insurance information in the app, and execute our “Reimbursify Consent Form” for us to then submit invoices on your behalf. In order to track any decisions/payments after our submission, you must refer to the Reimbursify app. This practice cannot answer questions related to your reimbursements and has no involvement with the reimbursement process other than, as a courtesy to you, submitting your invoice for you.

Payment Terms

Payment is due immediately before and/or immediately after services are rendered. The practice only accepts cash, credit cards, and debit cards (including, where appropriate, HSA debit cards). No other payment forms will be accepted!

Late Cancellations / No-Shows / Discharge After Three Strikes

Scheduling and timeliness is important to the smooth operation of this practice and the care and attention this practice can provide. You must notify the practice at least 24 hours prior to your appointment if you need to cancel or reschedule. Failure to cancel within the 24-hour window will result in a $50 late cancellation fee. No-shows will also receive the $50 fee. After three no-shows, the practice may in its discretion immediately discharge you as a patient.

Declined or Otherwise Insufficient Payment; Discharge if Unresolved

Payment is due no later than the completion of service and payment must be completed prior to your leaving the office. Paying the practice late for services already rendered is not an option. In the event that you provide credit/debit card information that is incomplete or inaccurate or outdated, for any reason, it is your responsibility to furnish correct card information that would permit the payment transaction to go through prior to your departure from the facility. It is your responsibility to ensure that you arrive at your appointment with an active method of payment with sufficient funds. If (and only if) payment is declined by your payment processor, or you make insufficient payment of your balance due, you may ask for, and the practice may choose to grant, a 24-hour extension window for you to complete the payment electronically or through delivering the full balance in cash. At the conclusion of the 24 hours, if you fail to settle your balance with the practice, the practice may in its discretion immediately terminate the relationship and discharge you as a patient. Any collection, legal, bank, or other fees incurred as a result of failure to pay will be passed on to the non-paying patient.

Acknowledgement and Agreement

I have read and understand the financial policies of Razia Jayman-Aristide, MD PLLC. I agree to abide by the terms outlined above and accept full responsibility for any and all charges for services rendered to me. If I choose to challenge or otherwise revoke my acceptance of any portion of this form, I must exclusively do so in writing to the practice through the patient portal and not orally. I understand that acceptance of this payment agreement in full is required, so refusal or revocation of my agreement in full will result in immediate discharge from the practice with no notice.