CREDIT GUARANTEE AUTO INSURANCE ASSIGNMENT PERSONAL BALANCES
INSURANCE ASSIGNMENT Our Auto Insurance Assignment Program is designed to render you immediate care and keep your out-of-pocket expenses to a minimum. As a courtesy to you, we will bill your insurance carrier on your behalf and wait up to 2 months for payment. Please remember, however, that you are ultimately responsible for payment. As a prerequisite, we ask that you provide a credit card to guarantee payment of your bill and that you provide us with the following: Your complete automobile insurance information Your family health insurance plan information FILING PROCEDURE We will periodically submit claims on your behalf to both your automobile and health insurance carriers. Any overpayments resulting in credit balances will be refunded promptly at the conclusion of your care. Balances not paid within 2 months after conclusion of your care will be charged to your designated credit card below. You will be sent a payment voucher. Should settlement be reached prior to the 2 month grace period or should care be terminated for any reason prior to your physician dismissal all balances become due immediately, will be charged to your credit card and are subject to monthly interest charges. CREDIT CARD: AMEX VISA MC DISCOVER
CARDHOLDER NAME CARD # EXP. DATE
I agree to the above terms and authorize you to bill the charge card. I understand that should payment not be received within 2 months after termination of my care or should I terminate care before being dismissed by your physician, I will be charged the amount outstanding on my account.
Signature _________________________ Date ________________
Credit Guarantee for Personal Balances
CREDIT GUARANTEE WORKER’S COMPENSATION CLAIMS INSURANCE ASSIGNMENT
Our Worker’s Compensation Care Program is designed to render you immediate care and keep your out-of-pocket expenses to a minimum. While your employer is responsible for reimbursement to you for medical expenses incurred as a result of work injuries, you are ultimately responsible for health care services rendered. As a courtesy to you, we will bill your employer or his/her work comp carrier and wait up to 2 months for payment. As a prerequisite, we ask that you leave a credit card to guarantee payment of your bill. FILING PROCEDURE We will periodically submit claims on your behalf to your employer or his/her work comp insurance carrier. Any overpayments resulting in credit balances will be refunded promptly at the conclusion of your care. Balances not paid within 2 months after conclusion of your care will be charged to your designated credit card below. You will be sent a payment voucher. Should settlement be reached prior to the 2 month grace period or should care be terminated for any reason prior to your physician dismissal all balances become due immediately, will be charged to your credit card and are subject to monthly interest charges.
CREDIT CARD:
AMEX
VISA
MC
DISCOVER
CARDHOLDER NAME CARD # EXP. DATE
I agree to the above terms and authorize you to bill the charge card. I understand that should payment not be received within 2 months after termination of my care or should I terminate care before being dismissed by your physician, I will be charged the amount outstanding on my account. SIGNATURE DATE
Credit Guarantee for Personal Balances
CREDIT GUARANTEE INSURANCE ASSIGNMENT PERSONAL BALANCES
INSURANCE ASSIGNMENT Our Insurance Assignment Program is designed to keep your out-of-pocket expenses to a minimum. As a courtesy to you, we will bill your health insurance carrier on your behalf and wait up to 60 days for payment. Please remember, however, that you are ultimately responsible for payment. As a prerequisite, we ask that you leave a credit card to guarantee payment. FILING PROCEDURE Claims for initial services are submitted within 48 hours after your first visit. On Day 60, if the bill has not been paid by your insurance company, we will charge your designated credit card below for the amount of the claim. You will be sent a payment voucher. Any payments made on these claims thereafter will be immediately refunded to you. PERSONAL BALANCES Estimated personal portions are paid at the time of service unless you prefer to pay weekly. Weekly payments also require this credit card guarantee, and any personal balance not paid by Friday will also be automatically charged to your designated card below.
CREDIT CARD:
AMEX
VISA
MC
DISCOVER
CARDHOLDER NAME CARD # EXP. DATE
I agree to the above terms and authorize you to bill the charge card. I understand that should payment not be received within 60 days after submission of my claim, or should I terminate care before being dismissed by your physician, I will be charged the amount due. SIGNATURE DATE
Credit Guarantee for Personal Balances
CREDIT GUARANTEE FOR PERSONAL BALANCES
UNINSURED PATIENTS Patients who are uninsured or whose insurance does not cover chiropractic care because of high deductibles or other limitations are personally responsible for payment. Payments may be paid at the time of service or on the last visit of the week. Weekly payments require a credit card guarantee. As a service to you and to keep your account current, any balance not paid by Friday will be automatically charged to your designated card below. This procedure will enable you to spread out your payments if you wish and make them smaller while keeping your account current.
CREDIT CARD:
AMEX
VISA
MC
DISCOVER
CARDHOLDER NAME CARD # EXP. DATE
I agree to the above terms and authorize you to charge any payment not paid by the end of each week to the above credit card.
SIGNATURE
DATE
Credit Guarantee for Personal Balances