Patient Billing Policy & Benefits

Payment is due on the date that the service is rendered. We will verify your benefits and review them with you on your first office visit. Because benefit verification IS NOT A GUARANTEE OF PAYMENT, it would be in your best interest to contact your insurance company for this information also. If there is a discrepancy, we will re-confirm your benefits. Although we will file your insurance for you, it is YOUR obligation to know the chiropractic benefits your policy covers. Any un-paid balance will ultimately be your responsibility.

All fees are based on individual services rendered and may vary from visit to visit depending on the doctors specific recommendations. A complete list is available at the front desk.

Any financial arrangements are to be determined prior to services rendered. I agree to the above terms and acknowledge that in the event there is an outstanding balance which fails to be cured within ninety (90) days, my account with Spiers Chiropractic Center WILL BE TURNED OVER TO COLLECTIONS. I understand that should this happen, I will remain responsible for the 25% collections fee AND 30% for attorney/courts fees.

Returned checks will result in a $30 insufficient funds fee. This will be added to any outstanding balance and will be due upon notification of said fee.

By signing this form, you're indicating that you understand and agree to ALL the above terms.

ASSIGNMENT OF BENEFITS, ASSIGNMENT OF RIGHTS TO PURSUE PERSONAL INJURY, WORK COMP, ERISA, AND OTHER LEGAL AND ADMINISTRATIVE CLAIMS ASSOCIATED WITH MY HEALTH INSURANCE AND /OR HEALTH BENEFIT PLAN (INCLUDING BREACH OF FIDUCIARY DUTY) AND
DESIGNATION OF AUTHORIZED REPRESENTATIVE

Provider Name: L. Denton Spiers, D.C.
Clinic: Spiers Chiropractic Center
Address: 5128 Old Hwy. 11, Suite 1, Hattiesburg, MS 39402

I hereby assign and convey directly to the above-named health care provider, as my designated authorized representative, any and all medical benefits and/or any insurance reimbursement, if any, otherwise payable to me for services, treatments, therapies, and/or medications rendered or provided by the above-named health care provider, regardless of its managed care network participation status. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize the above-named health care provider to release all medical information necessary to process my claims. Further, I hereby authorize my plan administrator fiduciary, insurer, and/or attorney to release to the above-named health care provider any and all Plan documents, summary benefit description, insurance policy, and/or settlement information upon written request from the above-named health care provider or its attorneys in order to claim such medical benefits.

In addition to the assignment of all medical benefits and/or insurance reimbursement above, I also assign and/or convey to the above named health care provider any legal or administrative claim or chose an action arising under any group health plan, employee benefits plan, health insurance or tort fees or insurance concerning medical expenses incurred as a result of the medical services, treatments, therapies, and/or medications I receive from the above-named health care provider (including any right to pursue those legal or administrative claims or chose an action). This constitutes an express and knowing assignment of ERISA breach or fiduciary duty claims and other legal and/or administrative claims.

I intend by this assignment and designation of authorized representative to convey to the above-named provider all of my rights to claim (or place a lien on) the medical benefits related to the services, treatments, therapies, and/or mediations provided by the above-named health care provider, including rights to any settlement, insurance or applicable legal or administrative remedies (including damages arising from ERISA breach of fiduciary duty claims). The assignee and/or designated representative (above-named provider) is given the right by me to (1) obtain information regarding the claim to the same extent as me; (2) submit evidence; (3) make statements about facts or law; (4) make any request including providing or receiving notice of appeal proceedings; (5) participate in any administrative and judicial actions and pursue claims or chose in action or right against any liable party, insurance company, employee benefit plan, health care benefit plan, or plan administrator. The above-named provider as my assignee and my designated authorized representative may bring suit against any such health care benefit plan, employee benefit plan, plan administrator or insurance company in my name with derivative standing at provider's expense.

Unless revoked, this assignment is valid for all administrative and judicial reviews under PPACA (health care reform legislation), ERISA, Medicare and applicable federal and state laws. A photocopy of this assignment is to be considered valid, the same as if it was the original.

I HAVE READ AND FULLY UNDERSTAND THIS AGREEMENT.