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FINANCIAL POLICY We are committed to providing you the best possible care and are pleased to discuss our professional fees with you at any time. Your clear understanding of our financial policy is important to our professional relationship. Please ask if you have any questions about our fees, financial policy, or your financial responsibilities. Our office participates in several insurance plans. Each plan has its own set of rules and regulations. Our office participates in these programs to allow you (the patient) to reduce your health care cost in this office. · REFERRALS- If your plan requires a referral from your primary care physician it is YOUR responsibility to obtain it prior to your appointment and have it with you at the time of your visit. If you do not have your referral, YOU WILL BE RESPONSIBLE FOR ALL CHARGES UP TO THE DATE OF THE REFERRAL. It is then your responsibility to provide us with the referral as soon as possible. · DEDUCTIBLES & CO-PAYMENTS- By law we MUST collect your carrier designated co-payment at the time of service. Please be prepared to pay deductible or co-payment at each visit. · NON-COVERED THERAPIES- In the event that the your policy does not cover the cost for therapeutic modalities (i.e. muscle stimulation, ultrasound) you will be responsible for the cost of those services if they are chosen to be used. · NON-COVERED X-RAYS- With some insurance policies x-rays or re-examination x-rays will not be covered. You will be responsible for any charges that are not covered by your insurance company. We cannot guarantee payment as we are not the insurance carrier. However, as a courtesy we will confirm your coverage. Since we often are given misinformation it is our suggestion that you also confirm your chiropractic coverage. If claims are delayed by more than three months, we require you to reimburse our office in full for services rendered. THE PATIENT IS LIABLE FOR ANY AND ALL EXPENSES INCURRED IN OUR OFFICE. SIGNED_____________________________________________ · PATIENTS WITHOUT INSURANCE COVERAGE- Payment is expected at the time of service unless other financial arrangements have been made prior to your visit. · MEDICARE- We will submit to Medicare for the Medicare allowed amount. The patient will be responsible for the exam, x-rays, therapies, deductible and 20% co-insurance which can be billed to secondary insurance if you have one. (It will be the patient’s option to have x-rays taken at the Community Chiropractic of Sparta or go to a Medicare approved facility for x-rays). SIGNED_____________________________________________ THIS APPLIES TO TODAY’S VISIT AND ALL FUTURE VISITS. OUR OFFICE ACCEPTS CASH, CHECKS, MASTERCARD AND VISA To: Community Chiropractic of Sparta IN CONSIDERATION OF YOUR UNDERTAKING TO TREAT ME, I AGREE TO THE FOLLOWING: AUTHORIZATION TO RELEASE INFORMATION You are authorized to release any information you deem appropriate concerning my physical condition to any insurance company, attorney, or adjuster in order to process any claim for reimbursement of charges incurred by me as a result of professional services rendered by you, and I hereby release you of any consequence thereof. SIGNED_____________________________________________ BENEFITS ASSIGNED I hereby authorize payment directly to the Community Chiropractic of Sparta for professional services rendered and I shall be personally responsible for any unpaid balance to the Doctor. I hereby authorize the attending Doctor to release any information concerning my examination or treatment. SIGNED_____________________________________________ CREDIT CARD ON FILE I agree to place a major credit card on file with the Community Chiropractic of Sparta and hereby authorize you to charge my credit card for any delinquent balances over sixty days. SIGNED_____________________________________________ |