Acupuncture to the People, PLLC

Katy Barnhill, L.Ac.

(617) 594-5920

info@acupuncturetothepeople.com

 

I certify that I, and/or my dependent(s), have insurance coverage with

and assign directly to Katy Barnhill, L.Ac./Acupuncture to the People, PLLC, all insurance benefits, if any, otherwise payable to me for services rendered. The patient shall be responsible for all co-payments, co-insurance, and/or deductibles, all of which shall be due the time of service. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named acupuncturist may use my health care information and may disclose such information to the above-named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for

Missed Appointment / Late Cancellation Fee If a patient does not show up for their appointment or fails to cancel their appointment at least 24 hours in advance of their scheduled appointment, Katy Barnhill, LAc/Acupuncture to the People PLLC reserves the right to charge the patient a no-show/cancellation fee of $50.

Verification of the patient's insurance eligibility will be completed prior to scheduled visits. A patient who schedules an appointment and fails to provide insurance information prior to the initial visit are classified as "Self-Pay" and will be required to pay at the time services are

Katy Barnhill, L.Ac / Acupuncture to the People PLLC requires that almost all patients provide a form of payment ("Card on File") in case of further patient cost responsibility after insurance adjudication of their visit. If you choose to not leave a form of payment on file, all co-pays, deductible amounts, and/or self-pay fees will be due on the day of service. If for any reason payment is not provided on the day of service, you will not be permitted to schedule a follow-up without paying the unpaid balance.

Nonpayment In the event of past due accounts and/or uncovered services, patients shall receive an invoice statement. If payment is not made within 30 days of the original invoice date, the patient understands that Katy Barnhill, LAc/Acupuncture to the People PLLC reserves the right to discharge the patient from the practice and to seek full payment of the outstanding invoice.

By signing this financial policy, the patient consents to all the terms outlined above.