I agree to pay the full amount of Services rendered, according to the cash rates/ time of service rates of the Practitiioner, if my plan doesn't pay for any reason within 30 days of services rendered, I agree to be charged/ liable for these rates. I will allow/give permission Acupuncture for Wellbeing LLC to bill/submit my information for billing purposes to my Insurance Company. I agree to leave my billing information on file for future use if needed.
DISCLAIMER:
Benefit Check Disclaimer: While we try to be as accurate as possible when verifying benefits, your fees may change depending on your eligibility and benefits during the date of your sessions. This is an estimate as of today, and we won't know your exact fee until we bill your insurance and get your explanation of benefits back from your insurance company. You are also encouraged to call the number on the back of your insurance card and ask your member representative about your 'acupuncture, outpatient, office visit' benefits'. Please let me know if you have any questions about your benefits