It is the patient’s responsibility to provide our office with current insurance information. We will ask for your insurance card at your first visit and will copy for our records. We will request a copy at each annual office visit, or if you have not been seen in the past 6 months. If your insurance information changes at any time during your treatment, it is ultimately your responsibility to provide us with the new information as soon as it becomes active. If current information is not obtained at the time of service it will be the patient’s responsibility to pay the entire balance until current information is provided to our office. It is the patient’s responsibility to know their benefits and coverage

    Your insurance policy is a contract between you and the insurance company. As a courtesy and pursuant to contractual obligations we will file all your claims for you. However, we will not become involved in any disputes between you and your insurance carrier. This includes, but is not limited to, deductibles, copays, and non-covered charges.

    Some insurance policies require you as the policy holder to obtain a referral from your primary care physician, or student health center prior to receiving treatment at our office. It is your responsibility to obtain this documentation and present it to our office at the time of service. If this information is not obtained, you will be responsible for the entire balance of your account.

    Copays are due at the time of service. Copays are usually collected PRIOR to you seeing the doctor but may sometimes be collected after you have received treatment.

    NON-COVERED SERVICES Dry Needling, Cold Laser, Taping and Normatec are considered non-covered services and are subject to patient responsibility.

    MEDICARE If you are a Chiropractic Medicare patient it is your responsibility to pay for your exam on your first visit, at the time of service. While Medicare requires an exam they do not cover it. Exams are typically $60 - $80. Therapies are also not covered by Medicare, and would be your responsibility. Therapies are approximately are $20 - $28 and due at the time of service.

    Cash plans are available for patients who do not have insurance or do not wish to bill their insurance. Cash payments are $120 for the first visit and $60 for a routine visit. Payment is due at the time of service.

    SUPPLEMENTS/MERCHANDISE Payments for supplements and merchandise purchased in our office are due at the point of sale. We cannot bill insurance, worker’s compensation, or personal injury accounts for these items. These charges are the patient’s responsibility and are not covered by any insurance carrier. These items include but are not limited to, swiss balls, supplements, foam rollers, vitamins and minerals.

    The charge for a returned check is $30. This can be paid by cash, money order or charge. This will be applied to your account in addition to the original amount owed.

    We ask that full payment be made at the time of service unless a prior arrangement has been made, with either your doctor or our billing office. If you have a deductible plan, once insurance has paid you will be mailed a statement. Prompt and timely payment is appreciated. ANY OVERDUE BALANCES WILL BE CONSIDERED FOR COLLECTIONS.

    We ask that you keep all scheduled appointments. In the event that you are unable to keep your appointment we ask that you provide 24 hours notice, this will give us the opportunity to fill your cancellation. A $25 missed appointment fee may apply.

    From time to time you may accrue a credit balance. Credit balances will be refunded at the patient’s request. Refunds are made by check. After the request for a refund has been made, please allow time for review of your entire account and processing through our accounting system. Once approved please allow 30-45 days for your refund check to arrive.

    I have read InMotion Spine Muscle Joint's Patient Financial Policy and acknowledge my responsibility with my signature below.

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