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					                                                          FINANCIAL POLICIES
It is our desire to make chiropractic care affordable to everyone. The established financial policy is a zero balance policy which
means that full payment is due at the time of service unless financial arrangements are made. We do accept assignment of
benefits on most major insurance policies, worker compensation and personal injury. We also have affordable payment plans
available should you need to make extended payments on your account. Please read the following explanation of our financial
         No insurance, limited insurance
If you do not have insurance or it is limited for chiropractic care, payments will be arranged on a per visit, weekly or monthly pay
schedule. The first payment is due upon completion of your first visit.
         Insurance coverage
Assignment will be accepted on most insurances provided we have a valid insurance card, patient insurance verification form
signed, and if needed a referral from your Primary Care Physician (PCP). Your first payment is due upon completion of your first
visit. Co-payments are due each visit.
         Worker compensation
“You have the right to choose your own BWC Doctor”
Assignment of worker’s compensation claims are accepted provided that you:
    1. Have reported your injury to the appropriate work personnel
    2. Fully complete all necessary forms
    3. Provide all necessary accident information
    4. Provide information on any group health insurance or your BWC card
    5. Sign change of physician request for the individual claim (if changing doctors)
*If injury is from an auto accident while on the job you are required to bill worker’s comp first.
         Auto/Personal injury
We accept these on the following conditions:
   1. Information on all the applicable insurance must be furnished to enable appropriate billing.
      a) Your personal auto insurance
      b) Auto insurance of the car you were injured in
      c) Third party insurance information (other driver)
      d) Your group health insurance card
   2. We only bill group health insurance when auto insurance is not responsible for coverage
   3. Notification of accident to your automobile insurance agent
   4. Name of attorney handling accident (if you have an attorney)
   5. Fully complete all necessary forms including the assignment of benefits and direct payment
We accept full assignment on Medicare with presentation of your card. Secondary insurances will be filled after reply from
Medicare. Affordable payment arrangements can be made for your examinations, X-rays, yearly deductibles, co-payments and
non-covered services. All Medicare patients do receive advanced notice of non-covered services.
         General Financial Policy
Our returned check fee is $30. Our cancellation policy is a 24 hour notice on all no show appointment or a $25 charge payable
on your next visit may be assessed. All outstanding balances over 90 days due may accrue a 2% monthly interest charge
unless financial arrangements have been made.

Acceptance of insurance assignment does not in any way relieve you of full responsibility for your bill. However, we hope to
relieve you of most of the paperwork problems so you can focus on your health. If provider must seek collection of past due
accounts, the above signed agrees to pay all legal collection costs including court, and attorney’s fees.
 I have read and agree to the above financial policies.

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Date                                                 Patient’s Name

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