PATIENT FINANCIAL POLICY
Welcome to our practice and thank you for choosing us for your chiropractic care. We feel it is important for you, our patient, to be informed of the financial policies of this practice. We encourage you to discuss any questions or concerns you may have regarding these policies.
- Patients cannot be seen without a current insurance card. If you do not have a current insurance card at the time of the appointment, payment in full will be expected at time of service.
- If the insurance company requires a referral it is the patient’s responsibility to obtain the referral from their primary care physician prior to the visit. If a referral is necessary but not obtained the appointment will need to be rescheduled or the patient may pay for the visit in full at time of service.
- We will bill your primary and secondary insurance plans for all services rendered. You will be responsible at the time of service for payment of co-payments and charges for non-covered services billed to your insurance. You will also be responsible for your deductible. We do offer a time of service discount on services that may not be covered by your insurance. If you choose to pay at time of service to receive the discount, those services will not be billed to your insurance. In the event that we are not aware of a charge that is not covered by your insurance, you will be billed for the balance after we obtain a denial from your insurance carrier. If you have insurance coverage with a carrier that we are not contracted with, you will be responsible for payment in full at time of service.
- For your convenience we accept cash, check, Visa, MasterCard and Discover.
- Due to the additional handling and charges made to us by the bank, there will be a $30 charge for all returned checks. We will contact you and request a cash payment for the amount of the check and the added fee.
- Any account overdue by more than 60 days from insurance’s final payment for the visit may be referred to a professional collection agency.
- This office charges $20 for missed appointments without 24-hour notification.
- Treatment of minors: We realize that many families are in a state of change. Divorced, separated, single parents and blended families are now common. In many of these families the question of who is financially responsible for the child’s care can be complicated. The policy of this office is that the parent who requests treatment for/accompanies the minor is responsible for the fees incurred.
- Disability forms: Disability forms can be very time-consuming to research and complete. These may include forms such as AFLAC and FMLA. A charge of $10 for each form that is required to be completed will be payable at the time the form is presented for completion.
Agreement to Pay for Services
I agree that I may have to pay for the services provided to me by this chiropractic office. Even though I may have insurance coverage, I have final responsibility for payment to the practice. I therefore agree to pay for all medical charges my insurance does not cover either at the time of service or as soon as I receive notice. If I do not pay for the services within the specified time frame, I understand that I will also be responsible for all costs incurred by the practice in collecting such charges, including attorney fees, court costs and or collection expenses.