Chiropractic Care Financial Policy & Payment Agreement

Patient Information

Name: _________________________ Date: _____________ Date of Birth: __________________ Account #: _________

Financial Policy

Insurance Coverage

• We participate with many insurance plans and will submit claims on your behalf
• You are responsible for knowing your insurance benefits and coverage limitations
• Verification of benefits is not a guarantee of payment by your insurance
• You are responsible for all copayments, deductibles, and non-covered services

Payment Terms

1. Copayments are due at the time of service
2. Self-pay patients must pay in full at the time of service
3. Payment plans are available upon request and approval
4. Returned checks will incur a $30.00 service fee

Missed Appointments

• 24-hour notice is required for cancellations
• A $50 fee may be charged for missed appointments without proper notice
• Repeated missed appointments may result in discharge from care

Collection Policy

1. Accounts over 90 days past due may be referred to collections
2. Patient is responsible for any collection agency fees (up to 35% of balance)
3. Legal fees incurred in collection efforts will be added to the account balance

Agreement

I have read and understand the financial policy above. I agree to comply with these terms and accept financial responsibility for services rendered.

Signature: _________________________ Date: _____________

Print Name: ________________________

Clinic Name: _______________________ Provider: _________________________