Green Acupuncture

Green Acupuncture FINANCIAL POLICY rev. 1/16

Thank you for choosing us as your health care provider. We are committed to your treatment being successful. FULL PAYMENT IS DUE AT TIME OF SERVICE. We Accept Cash, Checks, American Express, Mastercard, Visa and Discover.

Prompt Payment Discounts Our fees are discounted for patients without Insurance coverage who are paying in full at the time of service. Through the Prompt Pay program, patients are able to realize this discount by eliminating the administrative costs associated with billing insurance.

Deductibles, Co-pays and Co-Insurance Your insurance policy is a contract between you and your insurance carrier. Policy benefits vary greatly from one carrier/plan to another. It’s important you review and understand your insurance benefits. Your insurance plan mandates that you are responsible for all deductibles/co-pays. Green Acupuncture is contractually obligated to collect these fees and we cannot waive them. We are committed to providing the best treatment possible for our patients and charge what is usual and customary for our area.

Regarding Insurance We will verify coverage prior to treatment. If for any reason we are not able to verify coverage prior to your treatment, you will be charged for each treatment until verification is obtained. Our fees are determined by the complexity of the case and the different services used during treatment. Any balance due on your treatments is your responsibility whether your insurance company pays or not. We cannot bill your insurance company unless you bring in all insurance information. In signing this document, you are assigning to this office the benefits to which you are eligible to receive for care rendered in this office. Additionally in signing this document you authorize the release of any information to any insurance company, adjustor or attorney that will assist in the payment of a claim. Some insurance plans pay directly to you the patient. If this occurs, you are responsible for forwarding these payments in a timely manner. Failure to pay in a timely manner will resort in the account being sent to collections.

Health Savings Account (HSA) Many companies are now offering a Health Savings Account (HSA) in conjunction with their high-deductible health plans. When you receive services at Green Acupuncture, you can use your HSA card to pay for expenses such as co-pays and deductibles.

Missed Appointments Our policy is to charge for missed appointments at the rate of a normal office visit unless cancelled at least 24 hours in advance. More than 15 minutes late is considered a missed appointment. Your treatments will be more effective if you follow your doctor’s guidelines and stick to your treatment schedule.

I have read the Financial Policy. I understand and agree to this Financial Policy. X______DATE______Signature of Patient or Responsible Party