Sunset Chiropractic Clinic

Optimal Health Plan

Terms of Acceptance

Payment Plans/Insurance Info

Professional Fee Schedule

(All fees are standard and primarily based on our professional association’s guidelines)

Our experience has shown that it is wise to have an understanding with our patients as to our office policies and fees. Therefore, this page has been prepared for your convenience and information. We offer several methods of payment for your Chiropractic Care at our office. Please read carefully and choose one of the plans listed below which best fits your needs. This information will enable us to better serve you and help to avoid misunderstandings in the future. If special arrangements are necessary please consult with the doctor. Our main concern is your health and well-being, and we will do our best to help you. We agree to bill your insurance company for you. In exchange, we need your assistance, and your commitment to and understanding of our payment policies.

We must emphasize that, as health care providers, our relationship is with you and not your insurance company. Payment in full is required for your first visit at the time services are rendered, excluding Auto and Industrial Injury (workers comp) claims providing that you have supplied us with all the necessary information and confirmation of chiropractic coverage. While the filing of insurance claims is a courtesy that we extend to our patients, all unpaid charges are your responsibility.

If the insurance company has not made payment within 60 days of the billing date, you will be responsible for the amount owing on that portion of your bill in full unless other arrangements have been made with our office. Any insurance payment we receive after your balance has been met will be submitted to you or may be applied to your account toward future payments. Again, your insurance is a contract between you, your employer, and the insurance company. We are not a party to that contract.

You may go to a printable version of this form and sign this form and bring it to your first appointment, or we will provide one for you when you come in.

Plan Qualifications

Plan #1 — Cash

Fees are to be paid at the time services are rendered, unless special arrangements have been made in advance.

Plan #2 — Insurance

If you have insurance which covers Chiropractic care, we will bill your insurance for you. You will need to supply us with your insurance information, on or before your first visit. Until we have the completed, necessary insurance information to verify chiropractic coverage, you will be required to pay for your care in full at the time services are rendered. Patients with "deductible plus 80% coverage" pay their 20% copay each visit in addition to meeting their yearly deductible. Assignment of benefits will be made to the clinic. However, in the event the check should come to you, you are expected to bring the check to us as long as you have an outstanding balance on your account. All unpaid charges will be your responsibility.

Plan #3 — Auto Injury

You will need to contact your auto insurance company immediately, sign PIP forms and supply us with the necessary billing information and attorney information (if applicable). Until necessary insurance information is gathered and verified for chiropractic care, you will be required to pay for your care in full at the time services are rendered. We will bill your insurance directly after verification of coverage. In the event the check should come to you, you are expected to bring the check to us.

Plan #4 — Industrial

You will need to report your accident to your employer immediately, bring in necessary insurance information, and sign industrial forms for billing. Until we have the completed necessary insurance information to verify chiropractic coverage, you will be required to pay for your care in full at the time services are rendered. We will bill your insurance directly. In the event the check should come to you, your are expected to bring the check to us.

I qualify for and understand Plan #_______ Requirements

Signature_______________________________________

Date________________

Terms of Acceptance

(You may go to the printable version of this page, print and sign it and bring it in to your first visit. If you don't care to do this, we will provide you with the form when you come in.)

When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective.

Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment.

Adjustment: An adjustment is the specific application of forces to facilitate the body’s correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine.

Health: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity.

Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body’s innate ability to express its maximum health potential.

We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal examination, we encounter non-chiropractic or unusual findings we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area.

Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. Our only Practice objective is to eliminate a major interference to the expression of the body’s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations.

I _________________________________________ have read and fully understand the above statements.

All questions regarding the doctor’s objectives pertaining to my care in this office have been answered to my complete satisfaction.

I therefore accept chiropractic care on this basis.

Signature_______________________________________

Date________________

Optimal Health Plan

GREAT NEWS!! We have found a way to once again offer an affordable, monthly payment option for those of you who do not have insurance coverage and would like to make your chiropractic care even more affordable!!

Our new Optimal Health Plan is now available for those of you who want to boost your immune system, get your body operating at its fullest potential, or just take care of those chronic headaches and backaches, while keeping the expenses at a minimum. The Optimal Health Plan is a personalized monthly payment arrangement that can save big $$$ for those of you who are committed to your health. If you are interested, please ask Carole or Dr. Laura to get you started on the savings!!