Payment for treatment: You agree to pay by cash, check ,or credit card on the day that treatment is rendered. Unless we approve other arrangements in writing, the balance on your account is due and payable when the services are rendered, and is past due if not paid by this time.
Insurance: If applicable, I hereby authorize my health insurance company or claims administrator (personal injury/car accident) to pay by check, and for it to be made directly to LiveSmart Chiropractic & Rehabilitation the expenses benefits allowable and otherwise payable to me under my current policy as payment toward the total charges or professional services rendered. I have agreed to pay in a current manner, any balance of said applicable charges. I agree that this office by given power of attorney to endorse/sign my name on any and all drafts for payment of my bill. Full payment is expected at the time of service unless prior arrangements have been made. It is the policy of this office that all services rendered are charged directly to you, the patient, and that ultimately the patient is responsible for all services, including those not reimbursed by third party payors. All insurance assignment patients must pay their deductibles in full and the co-payment at the time of service, or at the end of each week.
Missed Appointment Fees: Patients who do not show up for an appointment or cancel with less than 48 hours notice will be charged a the total cost of the visit unless otherwise stated by the provider . This fee must be paid before a new appointment is scheduled, and will be charged to the patient’s payment account on file. Providing updates to any and all contact information are the sole responsibility of the patient.
Credit History: We may report your account status to any credit-reporting agency such as a credit bureau for delinquent accounts. If your accounts become past due, we will take necessary steps to collect this debt. If we have to refer your account to a collection agency, you agree to pay all of the collection costs, which are incurred. If we have to refer collection of balance to a lawyer, you agree to pay all lawyers’ fees, which we incur, plus all court costs.
Returned Checks: There is a fee (currently $25) for any checks returned by the bank.
Waiver of Confidentiality: You understand if this account is submitted to an attorney or collection agency, if we have to litigate in court, or if your
past due status is reported to a credit reporting agency, the fact that you received treatment at our office may become a matter of public record.
Transferring of Records: You understand that you will need to request in writing, and pay a reasonable copying fee (currently $25) if you want to have a printed copy of your patient health record.
I certify to the best of my knowledge, the above information is complete and accurate. If using a health insurance plan and the information is not accurate, or if I am not eligible to receive a health care benefit through this practitioner, I understand that I am liable for all charges for services rendered and I agree to notify this practitioner immediately whenever I have changes in my health condition or health plan coverage in the future.
I understand that my chiropractor may need to contact my physician if my condition needs to be co-managed. Therefore I give authorization to my chiropractor to contact my physician, if necessary.
Insurance Disclaimer: “A quote of benefits and/or authorization does not guarantee payment or verify eligibility. Payment of benefits are subject to all terms,
conditions, limitations, and exclusions of the member’s contract at time of service.”
Your health insurance company will only pay for services that it determines to be “reasonable and necessary.” Every effort will be made by this office to have all services and procedures authorized by your health insurance company. If your health insurance company determines that a particular service is not reasonable and necessary, or that a particular service is not covered under the plan, your insurer will deny payment for that service. If my health insurance company denies payment,
I agree to be personally and fully responsible for payment. I also understand that if my health insurance company does make payment for services, I will be
responsible for any co-payment, deductible, or coinsurance that applies. Although rare, insurance companies may provide us with incorrect information about your health plan. Thus, I understand that it is ultimately my responsibility to verify my chiropractic insurance benefits.
Effective Date: Once you have signed this agreement, you agree to all of the terms and conditions contained herein and the agreement will be in full force and effect.