Forms and Policies

Financial Policy

We request that the fees for the services of that day be paid at the time of services, We are happy to accept your Cash, Checks or Credit Card.

When possible, 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. Payment will be due by you at the time of service for any non-covered services, deductibles or co-pays.

"ON THE JOB" INJURY (Worker's Compensation)
If you are injured on the job, your care should be paid for under your employer's Worker's Compensation Insurance. You will need to inform your employer of the accident and obtain the name and address of the carrier of their insurance. If your employer does not provide us with this information, if a settlement has cot been made within 3 months, or if you suspend or terminate care, any fees and services are due immediately.

Please notify your auto insurance carrier of your visit to our office immediately. Notify our office immediately if an attorney is representing you. Although you are ultimately responsible for your bill, we will wait for settlement of your claim for up to six months after your care is completed. Once the claim is settled or if you suspend or terminate care, any fees for services are due immediately.

We do accept assignment from Medicare. They usually send the check directly to our office. The service that Medicare usually will cover for Chiropractors is ONLY manual spinal manipulation. Medicare pays 80% of their allowable fee once the deductible has been met. You are required to pay the deductible and remaining 20% as well as any non-covered services. Our office completes and flies the forms for Medicare at no charge.

Please inform us of any secondary insurance you may have. We will assist you if you need help in filing.

The doctor does participate in a number of HMOs. The HMOs for the most part do require a referral from your primary physician (MD or DO). The HMO may require you to pay a co-payment at the time of service and may have limitation on the number of treatments they allow.

Click here to download the form (pdf 479 KB)

Missed Appointment Policy

We want to thank you for choosing us as your chiropractic health provider. In order to provide you and our other patients with the best optimal spinal care, we request at least 24 hours notice for any broken or cancelled appointments in order to reschedule. In addition, this will allow us to offer your cancelled time to other patients.

Since our office does not charge for broken or cancelled appointments, please realize how important it is to keep your appointments. Thank you for your consideration of our policy and for the opportunity to be your Chiropractic Office of choice.

Patient Health Information Consent Form

Click here to download the form (pdf 502 KB).

Call 773-334-1515 for an Appointment