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Fees & Terms

I hereby acknowledge financial responsibility for payment of goods and services provided by Chronic Docs Scheduling Services. I understand that once I sign this form I will be charged today to secure my appointment time and that amount will be deducted for my doctors visit Fee. Should I NOT be able to attend my virtual appointment on my scheduled day and time I understand I do NOT loose this payment it will be transferred over and is able to be rescheduled. ***You understand that there is another State fee through the OMMA that is paid directly on their site and is a different fee than the doctor fee.

**The Credit Card charge will show up as HIVE Staffing on your bank statement.

The price I have agreed to is the following:

• Doctor Visit Fee: $25.00 (this fee is for the doctor visit )
• Optional OMMA Document Uploads: $25 (Not Required- You can complete yourself BUT if you would like assistance and for us to complete your application with the OMMA this is the fee for our help)
• OMMA State Fee: $22.50 if you have Sooner Care or Medicare and $105 if you do not. (This state fee is paid by debit or credit card directly to OMMA not to Chronic Docs.)