I understand that any service that are not covered by my insurance are my responsibility and are due and payable on the day of the treatment. If correct insurance information or referral is not presented at the time of service, I am responsible for the full amount of charges incurred. If I do not have medical insurance, arrangements can be made.
I am aware that if my insurance company directly sends me a payment for services provided at Tara Acupuncture Clinic, I am obligated to forward it to the Tara Acupuncture Clinic within 7 days of receipt.
Many of insurance companies do cover acupuncture care but this office makes no representation that yours does. Insurance policies may vary greatly in terms of deductible and percentage of coverage for acupuncture care. Because of the variance from one insurance policy to another, we require that you, the patient, be personally responsible for the payment of your deductibles, as well as any unpaid balances in this office. If you cannot pay your balances in the full amount, a financial plan will be made available to you. We will do our best to verify your insurance coverage and will bill your insurance in a timely manner.
Any unpaid balances will be considered past due 30 days following insurance reimbursement and referred to collection. Past due balances may have an interest charge of 2.0% applied per month.
There will be a $25 charge for returned checks.
The potential benefits: acupuncture may allow for the painless relief of one’s symptoms without the need for drugs and improve balance of bodily energies leading to the prevention of illness, or the elimination of the presenting problem.
Voluntary Termination of Care
If you suspend or terminate your care at any time, your portion of all charges for professional services is immediately due and payable to this office. All services rendered by this office are charged directly to you, and you, ultimately will be responsible for payment regardless of your insurance coverage.
I have read and agree to the above.
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