Complete Care of Colorado Financial Policies

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					                       Complete Care of Colorado Financial Policies

Complete Care of Colorado (CCC) is committed to providing you with the best general,
preventative and complimentary medical care. The following information outlines financial
responsibilities related to payment for professional services.

Financial Responsibility and Insurance

You, the patient is ultimately responsible for all charges associated with your care regardless of
insurance coverage. We require payment at the time of service unless other arrangements have
been made. It is your responsibility to check with your insurance company on co-payment
amounts as well as any deductibles. We will assist you in billing your insurance company for
contracted services. Your insurance company, however, may deny payment for non-contracted
services. These services may include but not limited to medical, chiropractic, acupuncture,
preventative medicine procedures, massage therapy, physical therapy, nutritional
recommendations and supplements. Before starting medical services and treatment at your first
visit we will require all of your insurance information and a copy of your driver’s license or state
issued identification card. If you have any questions about your insurance coverage please feel
free to call us at 303.659.0805. Your signature below indicates that you have read and agree to
this Financial Policy.

Separate Billing

If your condition requires a referral to another physician or diagnostic facility you may receive
bills from multiple parties. These may include but not limited to diagnostic facilities, physicians,
laboratory services, radiology and durable medical equipment (Tens units, braces and supports).

Payments and Insurance

We require payment for office visits that require the doctors time, (disability forms, FLMA paper
work, medical visits), at the time of service. If your condition requires multiple visits your co-
payment amount will be factored in the total bill. We accept checks, Visa, Master Card, cash,
FSA and HSA. We also accept Care Credit and payment arrangements.

Payment arrangements will be handled through our office manager during our business hours
which are Monday, Wednesday, and Thursday 8:00 A.M. to 6:00 P.M. and Tuesday 7:30 AM to
4:30 PM. Please call 303.659.0805.

If you are a member of a PPO or HMO managed care plan which we have a contract, we must
have a copy of your insurance card. You are ultimately responsible for knowledge of specific
coverage guidelines and requirements pertaining to referrals, co-pays of your individual plan. If
we can assist you in determining insurance coverage of your specific plan please let us know by
calling or asking the front office staff before or during the time of your first or subsequent visits.
CCC participates in all major insurance companies some of which are listed below.

       United Health Care
       Cigna
       Blue Cross/Blue Shield
       PHCS
       Aetna
       Kaiser – chiropractic only
       Medicare – chiropractic only

Medicare Billing Guidelines

The only service covered by Medicare at CCC is manual manipulation of the spine by a
chiropractic physician. All examinations, re-examinations, x-rays or diagnostic or other
preventative or therapeutic services by any provider at this office will be considered a Non-
Covered Service. If we are billing Medicare for you there will be additional expenses. We do
not bill secondary insurance. Please be advised that your secondary insurance will only approve
payment for Medicare approved services. Therefore, any Non-Covered Service at CCC will not
be approved by your secondary plan.

Discounts and Billing Statements

If you do not have insurance we offer a 20% discount for cash-paying patients. If we are sending
you a statement you will not be considered a cash-paying patient. If you have a high deductible
health plan you will be considered cash paying.

Our statements are sent out monthly. If you do not receive a statement from us it is your
responsibility to call us and let us know that. If you receive more than two statements from us
and have insurance you should take the initiative to call your insurance carrier about it and their
lack of response. Then call us if you have additional questions at (303) 659-0805.

If you have made payment arrangements with CCC we expect you to be timely. If you cannot
keep them on a timely schedule and your balance, no matter how small the amount, becomes
more than 120 days old, we will proceed to send your balance to our collection agency and
terminate you as a patient from CCC. Further, if we are in dispute with your insurance company
for any reason and your balance aging is greater than 90 days you will be converted to cash-
paying and appropriate discounts will apply.

Treatment of a Minor

If the patient is a minor (under the age of 18), the parent or guardian must sign below. The
parent, guardian, or unaccompanied minor is responsible for any payment due at the time of
service, and providing required referrals, insurance and picture ID cards.

We can discuss only billing information (no medical information) on an account for a patient over
18 years of age, regardless if the patient’s parent, guardian of the subscriber is financially
Workers Compensation, Third Party and Motor Vehicle Accidents

If your case involves worker’s compensation we will require a referral from your worker’s
compensation doctor or signed authorization from your adjustor before treatment begins. There
are no exceptions, as Colorado worker’s compensation laws require this.

If you were involved in a motor vehicle accident or are involved in a third party claim we do
accept Med-Pay or Liens. If you have Med-Pay we will bill your auto insurance company
regardless of fault. If your care requires more treatment than what your policy coverage limits
are you will need to make payment arrangements or retain an attorney. If your case is a lien the
following conditions apply. We require you to be represented by an attorney or appropriate
payment arrangements with our Office Manager before treatment can begin.

       If you have been seen in our office due to an Automobile Accident and still
        have an outstanding balance after you have been dismissed, you will be
        responsible for a $50.00 a month payment 90 days from the day that you are
        discharged from the office.

Additional Charges

For checks returned for “non-sufficient funds” - $40.00.

For all appointment cancellations of less than 24 hours or “No Call/No Show” – $25.00

Patient Signature_____________________________________ Date_______________________

Parent or Legal Guardian_______________________________Date_______________________