BURGUNDY PRIME


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Forms & Policies





ONLINE BILL PAY





Click on the link below to pay your statement online. Should you wish to pay over the phone, a member of our staff will be happy to assist you.





FORMS





Please be sure to complete all necessary paperwork by the time of your first appointment. Should you need additional documentation or run into difficulties accessing and completing paperwork, a member of our staff will gladly assist you.


2023 Consent Forms
New Patient Paperwork
Release of Information TO Burgundy Prime
Release of Information FROM Burgundy Prime

POLICIES





Payment

Payment is due at the time of services rendered. We accept cash, check and all major credit cards as forms of payment. You can also pay online at the bottom of this page.


Cancellation Policy

If you are unable to attend a session, please make sure you cancel at least 24 hours beforehand. Otherwise, you will be charged for a $25 no-show rate. Three subsequent no-show fees will result in a $50 charge per missed appointment.


Confidentiality & Privacy

The Heath Insurance Portability and Accountability Act (HIPAA), protects the relationship between a client and a healthcare provider, and information cannot be disclosed without written permission. A clinical summary is provided upon written request only. ​


Questions?

Please contact our office with any further questions and a member of our staff will be happy to assist you. We look forward to hearing from you!



OUR OFFICE





1337 South International Parkway
Suite 1301
Lake Mary, Fl 32746

Phone: 407-878-0022
Fax: 888-815-1039



Monday: 8:00am to 5:00pm

Tuesday: 8:00am to 5:00pm

Wednesday: 8:00am to 5:00pm

Thursday: 8:00am to 5:00pm

Friday: 8:00am to 5:00pm


Call us at 407-878-0022