Financial Agreement with Little Black Bag Medicine, LLC and Dr. Alison DiBarto


As a patient, it is in your best interest to know and understand your insurance plan benefits and your responsibility for any deductibles, co-insurance, or co-payment amounts prior to any visit.

Consultations through our office are not covered by insurance and your insurance company will not be billed. All fees are due 24 hours prior to the date and time of your consultation and payment is due at the time of shipping or service for your laboratory testing. If you would like a superbill to personally submit to your insurance please request one from our office.

Some services provided such as blood, urine, stool, and saliva testing are covered in some insurance contracts. In addition, you should be sure that your physician is NOT listed as a participating provider by your insurance company. If your insurance plan does not cover a service or procedure, you are responsible for payment of these charges. In the event that your insurance is not valid or your coverage was terminated at the time the services are rendered, you will be solely responsible for the full amount of your office visit and/or any procedures rendered.

In addition, if your insurance plan determines a service or procedure to be “not covered”, you will be responsible for the complete charge of such services. I agree to be responsible for the payment of all unpaid services rendered on my behalf or my dependents, including any fees for collection service needed.

Any cancellations of programs will be refunded only for consultations not utilized. All consultations that have been completed will not be refunded.

Thank you for your understanding,
Dr. Alison DiBarto-Goggin


By signing this form you acknowledge that our services are cash-based and your insurance will not be billed. Services that are performed by outside labs for blood, urine, stool, or saliva may be billed through insurance at your preference. You also acknowledge and agree to abide by our appointment policy.