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PATIENT CARE AGREEMENT
As a patient of Active Chiro Center I agree to the following:
• If, for any reason, my insurance company does not make a complete payment to Active Chiro Center (ACC) within sixty (60) days of my office visit, I understand that I will be sent a bill explaining my amount due. If I do not fulfill my obligation by sending a payment to ACC within the following thirty (30) days, I hereby authorize ACC to debit my credit card for the total amount due.
• In the event that my insurance company denies payment or applies the visit charges to my deductible, I understand that I am responsible for the amount billed by ACC. If I do not respond to the bill and make a payment within thirty (30) days of the bill being sent, I authorize ACC to debit my credit card for the total amount due.
• In the event that my case is an accident, personal injury, or workman’s comp, I understand that ACC will pursue all efforts to receive payment from the responsible parties. However, once one twelve (12) month period has passed from my discharge date and payment has not been made to ACC, I authorize ACC to debit my card for the total amount due. I will be refunded should ACC ever receive payment in the future for the respective service(s).
• If a check that I have written to ACC is returned, I hereby authorize ACC to debit my credit card for the amount of the check plus any related service fees.
• If, for any reason, I am unable to make my appointment and I do not notify ACC at least one hour before the appointment time, I authorize ACC to debit my credit card for the cost of an office visit.
• We at Active Chiro Center strive to make your visit worthwhile and by providing these guide- lines, we can continue to offer you the best possible care.
If you have any questions or need to make special payment arrangements, please feel free to call us at 818-784-2278 or stop by our offices.
We appreciate your cooperation and look forward to servicing your health and wellness needs.
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