Patient Policies
Open Adjusting Environment:
I give Inner Health Chiropractic permission to treat me in an open room where other patients are also being treated. I am aware that other persons in the office may overhear some of my protected health information. Should I ask to speak with the doctor in private, the doctor will provide a room for those conversations. I understand that I may choose treatment in a private room rather than in the open adjusting area. This environment is used for ongoing care and is NOT the environment used for taking patient histories, performing examinations or presenting report of findings. These procedures are completed in a private, confidential setting. Please turn your cell phone OFF or on VIBRATE.
PATIENTS WITHOUT INSURANCE/SELF PAY/TIME OF SERVICE (TOS)
We request that 100% of each visit be paid at the time the services are received. Please ask the front desk about discount packages. We accept VISA, MASTERCARD, DISCOVER and AMEX.
GROUP OR INDIVIDUAL INSURANCE
Your insurance is an agreement between you and your insurance company. When possible, we will verify your benefits; however, the benefits quoted to us are not a guarantee of payment. It is to be understood and agreed that any services rendered are charged to you directly and you are personally responsible for payment of any non-covered services. As a courtesy to you, our office will complete any necessary insurance forms at no additional charge, and file them with your insurance company.
FLEX PLAN – HSA/HRA ACCOUNTS
Please inform us if you have a medical savings account, sometimes known as a flex plan. We will be happy to provide you with a statement of your charges for reimbursement.
PERSONAL INJURY/AUTOMOBILE ACCIDENTS
Please present your auto insurance card, your health insurance card, and tell us if you have retained an attorney. There are three options available to a PI patient:
- Pay cash for your care and we will submit reports whenever necessary.
- We will bill (accept assignment) for the Med Pay portion of your auto insurance.
- We will accept a letter of protection or Doctors Lien from an attorney and await payment at the time of settlement.
WORKERS COMPENSATION
If you are injured on the job, your care should be paid for under your employer's workers compensation insurance. You will need to inform your employer of the accident. If a settlement has been made within 90 days, or if you suspend or terminate care, any fees and services are due immediately.
I have read and understand the payment policy of Inner Health Chiropractic. I understand that my insurance is an arrangement between myself and my insurance company. NOT between Inner Health Chiropractic and my insurance company. I request that Inner Health Chiropractic prepare the customary forms at no charge so that I may obtain insurance benefits.
If your account is sent to an outside agency for non-payment, a 35% fee will apply.
By signing below, you are agreeing to the above terms and conditions.