Business Arrangement Policy

We are dedicated to providing you with the highest quality care. If you have health insurance, we want to help you maximize your benefits. To do this, we ask for your cooperation and understanding of our payment policy.

Many healthcare costs are usually covered by insurance companies. Therefore, it is our policy to accept assignment for healthcare services provided to our patients under the following circumstances:

**Personal or Group Health Insurance:** Our office policy requires us to collect any portion of the bill that your insurance company does not cover at the time of service (e.g., co-payments and deductibles).

**If Underwood Chiropractic PLLC is not a network provider for your insurance company, you will be responsible for paying any outstanding balances not covered by your insurance.**

**Medicare Patients:** Medicare will only reimburse for spinal adjustments. Any additional spinal care, which may include extremity adjustments, Active Release Techniques (ART), or supportive modalities such as ultrasound or electrical stimulation (E-Stim), will be the patient’s financial responsibility, and payment is due at the time of service.

**Auto Accident/Insurance Coverage:** Patients may receive partial to complete credit, depending on their chiropractic insurance coverage. Patients are responsible for payment and may seek financial reimbursement pending settlement.

**Work Injury/Compensation Coverage:** With employer authorization, patients may receive partial to complete credit.

We want to emphasize that, as healthcare providers, our relationship is with you, not your insurance company. While we can assist with filing insurance claims, all charges are your responsibility from the date services are provided. The credit card on file will be charged 1-2 business days after you receive an email notification about an outstanding balance. Declined credit card transactions will incur a $25
fee the next business day if not updated. Additionally, patients will be charged $5.00 for all mailed statements.

We genuinely believe the strongest doctor-patient relationship is based on a clear understanding of treatment and financial responsibilities. Feel free to ask for clarification about any policies you do not understand.

The signature below is only an acknowledgement that you have read and received Underwood Chiropractic PLLC’s Business Arrangement Policy.

We are committed to providing excellent chiropractic care to you and all our patients. To ensure consistency in our scheduling, we have implemented an Appointment Cancellation Policy that allows us to accommodate everyone efficiently. When you schedule an appointment, that time slot is reserved specifically for you, and if it's not utilized, we cannot use it to treat another patient.

Our policy is as follows:

1. **24-Hour Notice Requirement:** We require at least 24 hours' notice if you need to reschedule your appointment. This advance notice allows us to offer the appointment time to other patients.

2. **Missed Appointment Fee:** If you miss an appointment (Monday—Friday) without providing the required notice, it will be considered a missed appointment, and a $65.00 fee will be charged. Please note that no future appointments can be scheduled, nor can records be transferred until this fee is paid. The credit card on file will be charged immediately.

3. **Late Arrivals:** If you arrive more than 15 minutes late for a scheduled appointment without prior notice, it will be considered a missed appointment, and the $65.00 cancellation fee will be charged to the credit card on file immediately.

***Please note: Appointments cannot be rescheduled or canceled through the text reminder system.***

If you have any questions regarding this policy, please feel free to ask our staff, and we will be happy to assist you.

Thank you for your understanding and support.

I have read and understand the Appointment Cancellation Policy of Underwood Chiropractic PLLC, and I agree to be bound by its terms.