Sunset Chiropractic Clinic

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_______________________________________

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