Financial Agreement - Natural Life Chiropractic

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Financial Agreement

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Natural Life Chiropractic
Lisa Orwick D.C.
 (520) 740-1718
Financial Policy
Our office strives to serve you in the best way possible.  In order to prevent confusion and to inform our patients of their choices, we have developed the following policies and explanations concerning financial arrangements.
As a courtesy to you, our office will bill your Insurance Company and wait for their payment on your account.  As you know, the health industry is changing everyday and they are looking for every possible way to cut their costs.  The filing and follow-up process costs us time and money and does not remove you from the following responsibilities: 1) Knowing what your insurance covers and what it does not.  You will be given a copy of the Verification of Benefits form upon your 1st or 2nd visit.  2) Knowing the amount of your deductible and co-pay (which applies after the deductible has been met).  Please remember most deductibles start over every year.  3) Read your Explanation of Benefits (EOB) so that you are aware of what is not being paid.
You are responsible for all charges that your insurance company does not pay within 90 days of their denial for payment.
We offer several therapies to enhance your chiropractic experience: interferential, therapeutic exercises, cold laser therapy, ultra sound, flexion distraction, massager, trigger-point therapy.  It is impossible for us to determine, at time of treatment, what your insurance company will pay.  We will not know until an EOB is received, at which time you will be informed and be responsible for denied portions.
Dr. Orwick’s office is one of the rare medical practices committed to respecting your busy schedule.  To maintain our high standard of care, patients are scheduled in 20 minute intervals and we are dedicated to running on time.  Our check-in requirement is to arrive 10 minutes prior to your appointment to complete paperwork, use the restroom, and relax in order to experience the maximum benefits from your treatment. 
We understand last minute changes like traffic or other obstacles occur and can result in running late for your scheduled appointment time.  In the event you are running late, please call the office immediately.  Our schedule is consistently full; however, IF we are able to fit you in we will be glad to do so to ensure consistency in your treatment.  Please note there may be a $20 late charge for rescheduling same day appointments.  Please see the following examples:
·         NO FEE - Your appointment is scheduled for 10:00am, you call to say you are running late and you arrive at 10:10.  You still have 10 minutes remaining of your original appointment time and we will be glad to offer an abbreviated appointment for treatment with no late charge fee.
·         LATE FEE $20 - Your appointment is scheduled for 10:00am, you call and notify us you are running late but are unable to get here prior to 10:20am (the conclusion of your appointment time).  We MAY be able to accommodate you between existing patients; however, you may receive an abbreviated appointment and you will incur a $20 same day rescheduling fee.  If we are unable to accommodate you the same day, the cancellation policy will apply.
·         SAME-DAY RESCHEDULING FEE $20 - Your appointment is scheduled for 10:00am, you call before 10:20 and notify us you will be unable to make your scheduled appointment time.  If we have an available 20 appointment time available later the same day, we will be happy to reschedule you to receive a full 20 minute appointment. However; this option monopolizes multiple  appointment times and a rescheduling fee of $20 will be incurred.  If we are unable to accommodate you the same day, the cancellation policy will apply.
Please note that your account must be current including any late or cancellation fees prior to receiving treatment.  
We are committed to your health, providing care at the time you have scheduled, and ensuring your positive patient experience.  We understand there can be changes in your schedule and we are happy to change your appointment time with a minimum of 24 hours notice.  However; cancellation within 24 hours of your scheduled appointment or a missed appointment will result in a $50.00 charge to your account.  All fees must be paid in full prior to receiving treatment.
If you have any questions regarding your bill, our charges, or this financial agreement, please feel free to contact us at any time.  We will be glad to explain in detail any question that you may have.
I have read and agree to the above financial policies.
Printed Name:_________________________________________________

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