Family Health History Template (Page 5 of 8) in pdf

Family Health History Template Page 5

Office Fee Schedule and Financial Policy

Service

Consultation

No Charge

Initial Visit

$75

Your initial visit includes:

Interview and Evaluation

$45

Neuro-spinal Exam

$30

Chiropractic Adjustment

$35

Chiropractic Report

No Charge

Dynamic Exam

$30

Adjustment

$35

Insurance/Personal Injury Reports $50-$125

Financial Policy and Chiropractic Active Life Plans

We are committed to providing you with the best chiropractic care possible in a caring

environment and have established our financial policies to achieve that goal. You will be

expected to pay for your chiropractic care at the time service is rendered unless you arrange an

Active Life Plan in advance. Active Life Plans include Corrective Adjustment Plans (CAP),

Wellness Adjustment Plans (WAP), or Family Adjustment Plans (FAP). These Active Life Plans

are designed to be the most cost effective way to keep you and your family as healthy as

possible. Details of these plans will be discussed with you during your Chiropractic Report.

If you have insurance that covers chiropractic, we will give you all of the

Health Insurance:

information you need to get reimbursed quickly. This includes your diagnosis, prognosis,

and copies of your records or reports. We have found it is easier for your record keeping,

and ours, if we give you receipts at the end of your first visit and then every Wednesday

thereafter. Just send in your claim form and your insurance company will communicate with

you about your reimbursement. Remember, your agreement with your insurance company

is between you and them.

I have read and I understand the above policies.

__________________________________________________

Patient Signature

Date

Family Health History Template Page 5