Patient Financial Responsibility Form


Patient Financial Responsibility Form
Because we are focused on overall health and wellness it is important to us that you understand the terms “Medically
Necessary” and “Clinically Appropriate.”
“Medically Necessary”: Is defined by your insurance carrier as treatment or service that is specific to your diagnosis and
which your insurance company will pay for per your contract with them. The insurer only pays for chiropractic care that
has a direct connection to documented improved function. There may be specific limits to your coverage or specific
services that are not covered and this also is determined by your carrier.
“Clinically Appropriate”: For example, if you have a neck or lower back condition, your treatment plan may have to be
extended beyond the insurance company’s standardized limitations in order to provide you full pain relief. At some point
later in your treatment, we may not be able to document significant improvements in range of motion or other objective
functional capacity measurements as the insurers often require. Insurance companies often deny care at that point despite
the fact that the treatment continues to manage, reduce or eliminate your pain. This is “clinically appropriate” for your
circumstances, but may not be considered “medically necessary” by your insurance carrier.
Your insurance company makes the final determination on whether a service is medically necessary and will be covered
by insurance.
Dr. Moran has advised me that:
1.) Many insurance companies permit collection of payment for services directly from the patient if the patient
requests the services and if the patient is informed in advance that the services are not covered or may be denied
as not medically necessary; and
2.) It is the patient’s financial responsibility to pay for these services.
I understand it is my responsibility to confirm my coverage with my insurance carrier and that Fountain Chiropractic
Clinic may verify such coverage as a courtesy to me, but that Fountain Chiropractic Clinic cannot be held responsible or
liable for inaccurate information provided to it by my insurance carrier.
My signature below acknowledges that:
1.) Fountain Chiropractic Clinic has discussed medical necessity limitations, clinically appropriate care, and the fact that
my insurance company may deny treatment as not medically necessary;
2.) I have been informed of my financial liability directly to Fountain Chiropractic Clinic if my insurance company denies
all or part of these services as not medically necessary;
3.) I fully accept the financial responsibility to pay Fountain Chiropractic Clinic for any services I choose which my
insurance carrier deems to be not medically necessary.
Patient Name: ______________________________________________
Patient Signature: ___________________________________________
Date: _____________________________________________________


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