Forms and Financial Responsibility

As a patient of Menlo Medical Clinic you will be required to sign a financial responsibility and authorization for treatment form. 

On occasion your insurance may determine the care you have received is NOT a covered benefit.  Please read your insurance handbook and be aware of what your insurance offers for benefits.  When in doubt contact your insurance company directly for clarification.  You will be responsible for care not covered by your insurance plan.

  • Not a Covered Benefit - is not covered or only partially covered by your insurance plan, also excluded may be work injury or auto accidents.
  • Not deemed medically necessary - not provided as the result of illness or injury.
  • Before or after Eligibility - services provided during a period your policy is not in effect.

Co-pay Requirements

It is the policy of the Menlo Medical Clinic that patients are prepared to pay their required copayment at the time service is rendered.

Self-Payment or Self-Pay

Menlo Medical Clinic requires full payment at the time service is rendered.

Self Pay Financial Policy

  • All patients that present without valid insurance information are considered a Self-Pay Patient.
  • All Self-Pay patients are required to pay at the time service is rendered.
  • Please be prepared to make this payment with the front desk personnel after the visit.
  • Should you have insurance but are unable to provide information at the time of your visit you may contact our insurance verification specialist at (650) 498-6613.
  • You will be requested to fax or provide copy of the front and back of your insurance card for our records.  You can fax your insurance information to (650)322-1329.
  • Business Services will issue a refund check when payment is received from your insurance company.

Forms of Payment

We accept Checks, Visa, Master Card and American Express.