Health History — Past 6 Months
Check any of the following you have experienced in the last six months:
Payment Policy
Due to changes in health insurance fees, patient self billing has become a much more cost effective way for you, the patient, to get reimbursement for your care. Self billing allows us to keep our fees low so you can get the care you need without any added cost. Therefore, our policy is that all payment is due at the time of service and bills will no longer be sent to your insurance provider. Statements will be provided for individuals to submit their own bills ensuring that as your insurance provider pays for your care, they will send the reimbursement check directly to you.
All charges are due when services are rendered.
Authorization & Signature
I authorize this Chiropractic Office to provide me necessary services and accept responsibility for all charges incurred.