We strive to provide the highest quality Chiropractic health care while maintaining affordability for you, our patient. We have come to understand that even with insurance, MOST patients will experience at least some sort of “out of pocket” expense over the course of their treatments.
(1) ______Participating Insurances:Our office will accept your insurance on assignment as we do participate as preferred providers for many insurance plans. However, it must be fully understood that your Insurance policy is a contract between you and your insurance company. Our office will NOT enter a dispute with your insurance company over policy limitations or issues. This is your responsibility and obligation. All charges incurred are ultimately yourresponsibility. If you have a question or concern with your reimbursement, you will need to contact your employer or insurance company. Our office will file your claims for you and assist you in every way possible to ensure benefit recovery. We cannot be certain if your insurance covers chiropractic care, although most policies do provide coverage of some sort. The amount they pay varies from one policy to another. We will call to verify benefits on your insurance; however, the benefits quoted to us by your insurance company are not a guarantee of payment. It is our policy that any non-covered services rendered are charged to you directly and you are also responsible for payment of your deductibles or co-pays per assignment.
(2) ______Non-Participating Insurances:We will gladly bill your insurance company for you, and we will call to determine your chiropractic benefits. Payment is due at the time of service for all deductibles, copays, and non-covered therapies unless arrangements are made directly with our office staff.
(3) ______Patients without Insurance:We request that 100% of the examination and first adjustment be paid at the time of the visit, unless other arrangements have been made. Office policy is payment is due at time of services rendered thereafter. We gladly accept cash, check, Master Card, Visa, Discover or American Express. No insurance will be billed in this case.
(4) ______Secondary Insurance:Please inform us of any secondary insurance you may have. We will file and collectfrom your secondary insurance for services covered by the secondary payer.
(5) ______Flex Plans/Medical Savings Accounts:Please inform us if you have a medical savings account, or a 'flex spending plan'.
We will be happy to provide you with a statement of your charges for reimbursement.
(6) ______Health Saving Accounts (HSA)/High Deductible Health Plan:Please inform us if you have an H.S.A. As Chiropractic is a qualified expense and can be paid for through your H.S.A. and billed to your high deductible health plan
(7)______Personal Injury & “On the Job” or Workman’s Compensation: Most Personal Injury and Workman’s Compensation claims are paid 100%. However, it is your responsibility to provide our office with accurate documentation necessary to prove a valid claim, as well as the name(s) of any claims adjuster/attorney, etc handling the case, claims numbers and mailing address to send documentation and bills. Failure to provide the these will result in immediate conversion of your case to cash, and all payments will be due in full on receipt of our bill.
Please read the following office policies regarding your Insurance Assignments: Only for Insurance Cases
At the beginning of your treatment in our office we will verify your policy benefits. However, phone or fax verification of coverage is never a guarantee of their payment(s).
Returned checks and balances over 90 days may be subject to additional collection fees and interest charges of 5% per month. Charges may also be charged for continually missing appointments and those canceled without 24 hours’ notice.
Your insurance will be filed as a courtesy to you. We file insurance claims on a tri-weekly basis.
You will be responsible for your full deductible and co-payment or coinsurance. Payment is due when services are rendered. If your insurance company does not pay something that was anticipated, you will be responsible for the amount as soon as we/you are made aware of the denial.
If your insurance company has not paid a claim within sixty (60) days of submission, you agree to take an active part in the resolution of your claim. If your insurance company has not paid within ninety (90) days of submission, you are ultimately responsible for payment of any outstanding balance due.
Our fees are considered usual and customary by most insurance companies, and therefore are covered up to the maximum allowance determined by each insurance company. This statement does not apply to companies who reimburse based on an arbitrary schedule of fees bearing no relationship to the current standard of care in this area.
By signing I also authorize the release of any information concerning my health and health care services to my insurance companies, pre-paid health plans or my personal insurance company.
I have read & understand the specific financial policies for my personalized case of care here at Organic Approach Chiropractic LLC. I also understand that if I have insurance, a valid auto case or a workman’s compensation claim, my carrier may pay for some to most of the charges, but no benefits are guaranteed. I understand that I am ultimately financially responsible for all services not paid by insurances or other 3rd parties. Should there be a balance due at the end of my treatment plan, I will receive an invoice for the amount and pay it promptly, or contact the office to make payment arrangements. Finally, I understand that my insurance is an arrangement between myself and my insurance company, NOT between Dr. Donald Bretz D.C. and my listed insurance company.
Printed Name of Patient/Responsible Party:____________________________________
Signature of Patient/Responsible Party:_______________________________________
Date Signed:_______/________/ 2016 2017 2018 Office Staff Witness Signature:____________________________________