ASSIGNMENT OF BENEFITS AND PAYMENT AGREEMENT

1. Patient assigns to Greenawalt Chiropractic any and all benefits payable by patients insurance or
   health care plan(s) as a result of charges incurred by patient for services rendered by Greenawalt Chiropractic. Patient also assigns to Greenawalt Chiropractic any and all contractual rights patient has against any insurance company, health care benefit plan, or any other party contractually liable to patient for payment of health care costs incurred by patient as a result of services rendered by this chiropractic office. This assignment of benefits and contractual rights relating to those benefits includes, but is not limited to the following described policies or plans. This agreement nullifies any agreement now orin the future for any third party (attorneys) other than Greenawalt Chiropractic to receive any payments for any insurance benefits including Personal Injury Protection or Med pay for medical services provided and billed from this office, This is the financial agreement of patient and this chiropractic office to have directly
   sent to Greenawalt Chiropractic as addressed above.
2. Patient hereby directs all insurers and other persons responsible for patient's health care costs to make all payments for health care services rendered by this chiropractic office directly to Greenawalt Chiropractic.
3. Patient agrees that in the event patient receives any check, draft, or other payment subject to this Agreement, such monies will be held in trust for Greenawalt Chiropractic. Patient will immediately deliver said check, draft, or payment to Greenawalt Chiropractic. Greenawalt Chiropractic agrees to apply the proceeds from said check, draft, or payments to patients debt for services rendered. Any violation of this agreement will at Greenawalt Chiropractic's election terminate patient charge privileges with Greenawalt Chiropractic and bring any balanced owed by patient to Greenawalt Chiropractic immediately due and payable.
4. The assignment of benefits and contractual rights shall not exceed the total amount due Greenawalt Chiropractic for service rendered by this chiropractic office. Patient agrees that payment for services rendered by Greenawalt Chiropractic is due upon receipt of sald services and acceptance of patient's assignment of benefits is a convenience to patient and that Greenawalt Chiropractic may revoke this assignment at any time.
5. Patient agrees to waive any applicable statute of limitation.which may at any time interfere.with
   Greenawalt Chiropractic right to collect for services rendered by Greenawalt Chiropractic to
   patient.
6. Patient hereby authorizes Greenawalt Chiropractic to release and permit the examination and/or copying of any of patient's medical records, x-rays, laboratory reports and the results of all test of any time or character to such persons as Greenawalt Chiropractic deems appropriate.
7. Greenawalt Chiropractic is authorized to submit a copy of this Assignment, or notice thereof, with the initial claim form(s) or any claim thereafter which Greenawalt Chiropractic submits to third party payor(s) as notice to the third party payor(s) of the assignment and other agreements contained herein. A copy of this document shall be as binding as the document bearing original signatures. At the time each claim is submitted, a copy of the claim will be stored for safekeeping in patient's file.
8. In the event that any séction or provision of this Agreement is legally void, invalid, or unenforceable, all other sections and provisions of this Agreement shall remain in full force and effect.
9. The assignments and agreements contained in this document may not be revoked by patient without the express consent of Greenawalt Chiropractic.
10. Your chosen insurance company does not guarantee benefits until claim arrives; and at that time an Explanation of Benefits will be given by your chosen insurance company stating your exact benefits. Any billing to insurance that is not covered (pald) is patient responsibility.
11. PATIENT UNDERSTANDS THAT PATIENT IS FINANCIALLY RESPONSIBLE FOR ALL CHARGES FOR SERVICES RENDERED BY GREENAWALT CHIROPRACTIC. ANY LEGAL OR COLLECTION EXPENSES INCURRED BY THIS OFFICE TO COLLECT BALANCE OWED BY PATIENT WILL BE THE FINANCIAL RESPONSIBILITY OF SAID PATIENT.

GREENAWALT CHIROPRACTIC POLICIES                                                     MARCH 1, 2023

ALL COPAYS AND DEDUCTIBLES are due at the time of service. We accept cash, checks, Visa and MasterCard. We will submit an insurance claim on your behalf. We do NOT bill any secondary insurance. If your insurance changes, you must notify us immediately and provide a copy of your card prior to your next appointment. If you fail to give us your correct insurance information you may be responsible for your entire bill.

ALL ADULT PATIENTS MUST PROVIDE a valid driver’s license or state ID card.

CANCELLATION/RESCHEDULING: you must give us a 24 hour notice to cancel or reschedule your appointment. If you fail to give us this notice you will be responsible for a $40.00 fee.

As a courtesy, we will submit your claim to your insurance company, please realize that your insurance is a contract between you and the insurance company. We are not a party to the contract even though we may be a provider with the insurance. If your insurance denies, ignores, or refuses to pay your claims, the balance is due in full by you.

Your payment at time of service is based on the estimated amount your insurance company has advised us is your copay. Your insurance company informs us of their disclaimer stating what they tell us is your copay may not be correct and only when the claim is submitted will the correct copay be processed. In the case of any wrong information provided by your insurance company should cause the claim to be processed with a higher deductible, co-insurance, copay or denial, the balance is your responsibility. Denied claims from your insurance, you may be charged the balance in full. You will need to contact your insurance company immediately to give them the information they require to process your claim, or you will need to pay your balance in full.

REFERRALS AND/OR AUTHORIZATIONS required from your insurance company. If you need a referral scheduling an appointment. Primary care providers are not granting referrals after you have already had the appointment here. If the referral or prior authorization is not received prior to your appointment you will be responsible for the entire cost.

FEES. Bounced Checks are subject to a $25.00 fee. Collections fees will be added to your account for any balance that is forwarded to a collection company to collect non-paid accounts. No Show Appointment fees are $40.00. Service Fees of $10.00 added to each monthly statement when payment has not been made. Credit Card Surcharge of 3.5% will be added to all credit card payments automatically when paying by credit card. Debit payments do not have a surcharge fee. Fees are subject to change.

By initialing each section and signing below, you agree to the following: Authorization to use this form on all insurance submissions. Authorize release of information to the insurance companies to get your account paid. Authorize and assign direct payment for all services provided by Greenawalt Chiropractic to be paid directly to Greenawalt Chiropractic. And you authorize to have a copy of this to be used in place of the original. I have read the financial policies above, I understand and agree to all provisions contained within.