September 1, 2007
Please be advised effective September 1, 2007 there will be a $20.00 lab convenience fee when using our in
house lab. Due to rising overhead costs and decreasing re-imbursement, we are no longer able to provide
this service free of charge. Please note this fee is not covered or billable to your insurance company. If you
select not to participate with this convenience fee you will be given a lab prescription so that you may have
your labs done at your nearest participating provider. This fee is in addition to any other applicable
copayments.

January 1, 2008
Please be advised effective January 1, 2008 there may be a $25.00 form filing convenience fee when our
Doctors have to fill our paperwork for you. Due to the time it takes for some paperwork to be filled out, we
are no longer able to provide this service free of charge. Please not that this fee is not covered or billable to
your insurance company.
We thank you for your understanding.
Sincerely,
M.J. Galceran,M.D.
Aparna Hernandez, M.D.

I have read and agree to the above stated policies.