Chiropractor Intake Form (Page 5 of 5) in pdf

PAYMENT POLICY

Thank you for choosing ___________________ as your Chiropractic provider. We are committed to

providing you with quality and affordable health care. Due to some of the questions our patients have

regarding patient and insurance responsibility for services rendered, we have been advised to develop this

payment policy. Please read it, ask any questions you may have, and sign in the space provided below. A

copy will be provided to you upon request.

1. INSURANCE. We participate in most insurance plans, including Medicare. If you are not insured by

a plan we participate with, payment in full is expected at each visit. If you are insured by a plan we

do participate with, but do not have an up-to-date insurance card, payment in full for each visit is

required until we can verify your coverage. Knowing your insurance benefits is your responsibility,

please contact your insurance company with any questions you may have regarding your coverage. If

your insurance company requires a referral it is your responsibility to provide us with a referral dated

the day of your first visit from your primary care physician prior to your first visit. We are only able to

provide a summary of your chiropractic benefits.

2. CO-PAYMENT AND DEDUCTIBLES. All co-payments and deductibles must be paid at the time of

service. This arrangement is part of your contract with your insurance company. Failure on our part

to collect co-payments and deductibles from patients can be considered fraud. Please help is in

upholding the law by paying your co-payment at each visit.

3. PROOF OF INSURANCE. All patients must complete out patient information form before seeing the

provider. We must obtain a copy of your most current insurance card to provide proof of insurance. If

you fail to provide us with the correct insurance information in a timely manner, you may be

responsible for the balance of a claim.

4. CLAIM SUBMISSION. We will submit your claims and assist you in any way we reasonably can to

help get your claim paid. Your insurance company may need you to supply certain information

directly. It is your responsibility to comply with their request. Please be aware that the balance of your

claim is your responsibility whether or not your insurance pays your claim. Your insurance benefits

are a contract between you and your insurance company; we are not party to that contract.

5. CONVERAGE CHANGES. If your insurance coverage changes, please notify us before your next

visit so we can make the appropriate changes to help you receive your maximum benefits. If your

insurance company does not pay your claim in 90 days, the balance will automatically be billed to

you.

6. MISSED APPOINTMENT. Our policy is to charge $________.00 after one missed appointment not

cancelled 24 hours in advance. The charges will be your responsibility and billed directly to you.

Please help us to serve you better by keeping your regular scheduled appointment.

Our practice is committed to providing the best treatment to our patients. Our prices are representative of

the usual and customary charges for our area.

I have read and understood the payment policy and agree to abide by its guidelines.

______________________________________

_____________________

Signature of patient or responsible party

Date

Chiropractor Intake Form Page 5