Financial Policy: It is our firm belief that all our patients deserve quality care. For us to provide this level of service, it is important that our patients understand our financial policies.

If we are participating providers in your plan, we will accept assignment for payment and submit a claim on your behalf to the insurance company. You must provide our office with accurate insurance information for us to file your claim. Failure to provide accurate information may forfeit your right for us to file your claim. Some insurance companies require you to satisfy an office copay and/or deductible before they submit payment. We require copays and/or deductibles be paid at the time services are rendered. It is important to remember that your insurance coverage is a contract between you and your insurance company. You are responsible for any balances or charges not covered by your insurance.

If you receive a patient statement, please remember you have already received services from our office and the balance is your responsibility. If you are unable to pay your balance in full, please contact our billing department to make payment arrangements.

Assignment and Instruction for Direct Payment to Doctor: I hereby direct and instruct my insurance company to pay Discover Specific Chiropractic. A photocopy of this assignment shall be considered as effective and valid as the original. I understand I am financially responsible for any amount not covered by my insurance policy. I also authorize the release of any information pertinent to my case to any insurance company, adjuster or attorney involved in this case. This form is my signature on file.

Medicare Patients Only: Medicare will only pay for service that it determines to be “reasonable and necessary” under Section 1962(a) (1) of the Medicare law. If Medicare determined that a particular service, although it would otherwise be covered, is “not medically necessary” under Medicare program standards, Medicare will deny payment for that service. (X-rays and Examination) I have been notified by my physician that he/she believes that Medicare is likely to deny payment for my X-rays and Examination and I agree to be personally responsible for payment of the agreed services.

Privacy Policy: We are very concerned with protecting your privacy. We may disclose your health information to another health care provider or a hospital if it is necessary to refer you to them for diagnosis, assessment, or treatment of your health. We have more than one doctor in our office and your information may be shared with other doctors. You have the right to request that we do not disclose your health information to specific individuals, companies, or organizations. Any request, such as these, must be made in writing. However, we are not required to agree to you restrictions.

Your chiropractor and members of the practice staff may need to use your name, address, phone number, and your clinical records to contact you with appointment reminders, information about treatment alternatives, or other health related information that may be of interest to you. If this contact is made by phone and you do not answer, we will leave a voicemail. Our office sends out new patient letters, post cards, birthday cards and statements periodically.

By signing this, I hereby acknowledge that have read and understand Discover Specific Chiropractic’s privacy policy. I understand that I may obtain a copy of the privacy notice.