Patient-Doctor Agreement (7 of 7)
The purpose of this agreement is to make sure we are able to best serve you. The scheduled appointments are made for a reason, they attempt to keep patient wait times down and allow for the best patient care possible.
_________ I authorize the release of any records completed and/or obtained by Fisher Chiropractic to my insurance company, attorney, referral physician and/or insurance adjustor.
Cash Pay Patient Financial Policy- All fees are due at the time of service unless previous arrangements have been made with this office. We are happy to accept cash, check, MasterCard, Visa, Discover, and American Express. We do not accept Care Credit.
Medicare Financial Policy- Original Medicare covers 80% of approved services after the deductible is met. Medicare does not pay for evaluations, re-exams, or x-rays. Medicare will not pay for maintenance care, but episodes of care where notable progress is being made.
Major Medical/Group Insurance- Payment is expected at time of visit. Please give all insurance information (secondary policies included) to the Front Desk Coordinator along with a copy of your card(s) and a form of ID.
Auto Accident/Personal Injury- Fees are usually covered 100% for these injuries; however, YOU are ultimately responsible for any balance on your account. When using PIP, personal injury protection, you are responsible for providing this office with the name of your insurance company and the adjuster's name and contact information. You are also responsible for reporting the accident to your insurance company/agent. You hereby assign benefits payable for the eligible claims to Fisher Chiropractic for submitting your claims to attorney/insurance company and you authorize attorney/insurance company to issue payment directly to Fisher Chiropractic. In the case that you are no longer under contract with your attorney, whatever the cause, or your PIP is exhausted, you understand that you remain responsible for payment to the Provider for any services rendered and/ or supplies provided. You understand that this Assignment will apply to all eligible claims submitted by Fisher Chiropractic. If you are a Parent, Guardian, or Personal Representative, you confirm that you are authorized by the member to execute an assignment of benefit payments to Fisher Chiropractic.
IMPORTANT:
IMPORTANT: If you are using insurance, please bring a copy of your insurance card to your appt along with a form of ID. If you are using PIP, please have your adjuster's contact information and claim number. If you are under contract with an attorney, please have your attorney's contact information. There may also be additional paperwork that will need to be completed at time of arrival. We look forward to meeting you!