OUR FINANCIAL POLICY

Thank you for choosing us as your health care provider.  We are committed to your treatment being successful.  Please understand that payment of your bill is considered part of your treatment.  The following is a statement of our Financial Policy, which we require you to read and sign before your treatment.  All patients must complete our information and insurance form before seeing the doctor.

FULL PAYMENT IS DUE AT THE TIME OF SERVICE

WE ACCEPT CASH, CHECK OR VISA/MASTER CARD

FINANCING THROUGH CHIROPRACTIC FEE PLAN

FOR PATIENTS WITH INSURANCE

We will submit your visits to your insurance company. The balance is your responsibility whether your insurance company pays or not.  We cannot bill your insurance unless you provide us with all the insurance information needed.  Your insurance policy is a contract between you and your insurance company.  WE ARE NOT PARTY TO THAT CONTRACT.  WE WILL DO OUR BEST TO COLLECT FROM YOUR INSURANCE COMPANY THE FIRST TIME.  AFTER THAT, IT BECOMES YOUR RESPONSIBILITY.  We will provide you with an estimate of what your insurance will pay (this is only an estimate) and you will be expected to pay your estimated co-payment in full at the time of service.

USUAL AND CUSTOMARY FEES

Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary in our area.  Please be advised that some, and perhaps all of the services provided may be NON-COVERED SERVICES and not considered reasonable and necessary under your chiropractic plan.  You are still responsible for payment regardless of any insurance arbitrary determination of usual and customary rates.

MISSED APPOINTMENT FEES

Unless cancelled at least 24 hours (Regular Office Hours) in advance, we will charge for missed appointments.  This can range from $25.00 to $50.00.  Please help us serve you better by keeping your scheduled appointments.

Thank you for reading and understanding our financial policy.

I have read the Financial Policy and I agree to these policies.

X________________________________________________       Date___________________________