Welcome To Qiworks Community Acupuncture (Page 4 of 4) in pdf

FINANCIAL POLICY

$15-$40 sliding scale per treatment, plus a one-time $15 intake fee for new patients.

You decide what to pay at each visit. There is no income verification.

Cash, checks, and credit cards accepted.

Payment is expected at the time of service. There is a $15 charge for returned checks.

We do not bill insurance or provide information to insurance companies such as diagnosis or procedure codes.

If you need a receipt to submit to your insurance/flex plan, we can email or print out a receipt upon request.

LATE ARRIVAL POLICY

QiWorks is a low-cost, high-volume Community Acupuncture Clinic.

We keep our fees low by scheduling patients every 10 minutes.

If you are late, we will do our best to squeeze you in, but we will first treat the patients who arrived on time.

If you are more than 10 minutes late, we may have to reschedule your appointment.

CANCELLATION POLICY

Please provide us with at least 24 hours’ notice if you need to CANCEL or RESCHEDULE an appointment.

All appointments that are cancelled or changed with less than 24 hours’ notice, or are missed altogether

without letting our front desk know, will be charged a $15.00 fee.

We recognize that emergencies happen and will consider emergency scheduling conflicts on a case-by-case basis.

Because several people are being treated in the same room at once, it is vital that we work together to respect

your privacy and the privacy of others.

Employees of QiWorks may review your file but otherwise it will be kept confidential and can only be released

with your written consent or when required by law.

I agree to the above policies:

Printed Name: __________________________________________________________________________

Signature: ______________________________________________Date:

Signature of Parent or Guardian (if under 18): _________________________________________________

Welcome To Qiworks Community Acupuncture Page 4