I understand and agree that if I have health and/or accident insurance, these policies are an arrangement between the insurance carrier and myself. Further, I understand that this health care provider will prepare reports and forms to assist in reimbursement from the insurance company. Any amount authorized to be paid directly to this office will be credited to my account on receipt. However, I clearly understand and agree that all services rendered to me are my personal responsibility for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered to me will be immediately due and payable. I understand that I am responsible for all attorney fees or collection fees related to the collection of my account.
I hereby authorize the doctor to examine and treat my child’s condition as he/she deems appropriate through the use of Chiropractic Health Care, and I give authority for these procedures to be performed. It is understood that nutritional recommendations and neurologic treatments are considered none covered services in a Chiropractic setting by insurance companies. They are categorized as experimental treatments and are therefore rendered a non-covered service. The Doctors of Fulda Family Chiropractic do not claim or aim to treat any disease condition. It is our goal to examine the patient, and give musculoskeletal, neurological, and nutritional support to optimize the body’s ability to function. It is understood and agreed the amount paid to the Doctor for imaging is for examination only and the negatives will remain the property of this office, being on file where they may be viewed.