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Payment Policy
Thank you for choosing D r. Coats as your Chiropractic provider. We are committed to providing you with quality and affordable healthcare. Due to some of the questions our patients have regarding patient and insurance responsibility for services rendered, we have been advised to develop this payment policy. Please read it, ask any questions you may have, and sign in the space provided below. A copy will be provided to you upon request.
- INSURANCE. We participate in most insurance plans. If you are not insured by a plan we participate with, payment in full is expected at each visit. If you are insured by a plan we do participate with, but do not have an up - to - date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility, please contact your insurance company with any questions you may have regarding your coverage. If your insurance company requires a referral it is your responsibility to provide us with a referral dated the day of your first visit from your primary care physician prior to your first visit. We are only able to provide a summary of your chiropractic benefits
- CO - PAYMENT AND DEDUCTIBLES. All co - payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co - payments and deductibles from patients can be considered fraud. Please help is in upholding the law by paying your co - payment at each visit
- PROOF OF INSURANCE. All patients must complete out patient information form before seeing the provider. We must obtain a copy of your most current insurance card to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim.
- CLAIM SUBMISSION. We will submit your claims and assist you in any way we reasonably can to help get your claim paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance pays your claim. Your insurance benefits are a contract between you and your insurance company; we are not party to that contract.
- CONVERAGE CHANGES. If your insurance coverage changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 90 days, the balance will automatically be billed to you.
- MISSED APPOINTMENT. Our policy is to charge $56.00 after one missed appointment not cancelled 24 hours in advance. The charges will be your responsibility and billed directly to you. Please help us to serve you better by keeping your regular scheduled appointment.
Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area.
I have read and understood the payment policy and agree to abide by its guidelines.
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Patient Informed Consent Form and Arbitration Agreement
I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including examination, various modes of physiotherapy (ultrasound, muscle stimulation, micro current, stretching, exercise, etc.), physiological therapeutics (mineral/vitamin supplementation, homeopathic formulations, etc.) and diagnostic x - rays, on me (or on the patient name below, for whom I am legally responsible) by the Doctors employed by the clinic.
I understand that I have an opportunity to discuss with the Doctors employed by the clinic and/or with other office or clinic personnel the nature and purpose of Chiropractic adjustments and other procedures.
I understand and am informed that, as in the practice of medicine, in the practice of Chiropractic there are some risks to treatment, including but not limited to, fractures, disc injuries, strokes, dislocations, aggravations of inflammatory conditions, sprains and strains. I do not expect the doctor to be able to anticipate and explain all risks and complications, and wish to rely on the doctor to exercise judgement during the course of the procedure which the doctor feels at the time, based upon the facts then known, is in my best interest. I further understand that there is no guarantee or assurance as to the results of any procedures.
I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.