Dear patient, our financial policies have been established to ensure the best services can be provided to you and your family and any misunderstanding can be avoided. Our professional services are rendered to the patient and not the insurance company. The insurance company is responsible to the patient and the patient is responsible to the doctor. We will not provide services on the assumption that the charges will be paid for full payment of your bill. We will verify your insurance eligibility and, as a courtesy, submit your claim into your insurance carrier for payment. We will not be held responsible for any misinformation your insurance carrier gives this office upon verification of your benefits.
Missed Appointments
Not showing for your appointment if a problem for everyone. It delays your treatment, prevents another patient from coming in your place, and costs the office a great deal. Failing to contact this office 24 hours prior to your appointment can result in a charge for that missed appointment. This charge is solely your responsibility and not your insurance company’s. Additionally, if you arrive late for a scheduled appointment, we reserve the right to ask you to reschedule. Please help us serve you better by keeping scheduled appointments.
Group or Individual Health Insurance
Health Insurance is an agreement between you and your insurance company, not between your insurance company and this office. As a courtesy to our patients, our office will complete any necessary reports and forms at no charge to you, and then file them with your insurance company. It is to be understood and agreed that services rendered are charged to you and your insurance company. Should your insurance carrier deny payment, you are personally responsible. Insurance companies typically take 3-4 weeks to send payment to our office. If after 60 days our office has not received payment from the insurance company, you will be billed directly for the outstanding balance due.
Medicare Limits and Responsibilities
The only charge for chiropractic that is covered is manipulation of the spine. I accept responsibility to know the current Medicare guidelines and limits for covered services. I understand that Medicare may reimburse me for chiropractic adjustments, and that the Medicare program frequently does not consider treatments to me medically necessary. I accept responsibility to pay for all covered, non-covered and denied services. My physician has notified me that he or she believes that in my case Medicare is likely to deny payment for some or all services. If Medicare denies payment, I agree to be personally and fully responsible for payment. I understand that I must pay for services at the time of service. I also understand that Ferrel’s Chiropractic will bill all charges directly to Medicare as required by law. I authorize the release of my records as necessary for Medicare billing.
Patients without Insurance
Payment is due at the time that services are received unless other payment arrangements have been made. Should the need arise, please contact us immediately to discuss a mutually agreeable payment plan.
“On the Job” Injury
We will gladly bill your care directly to your employer’s insurance company, providing that we have received all forms related to your injury. Please understand that you must first report any work related injury to your employer and then follow the necessary steps to file a claim with your employers insurance.
Personal Injury and Automobile Accidents
We will gladly bill your care directly to the responsible party. Please present all forms related to your accident, including claim numbers from the insurance company. If an attorney is handling your case, please notify us immediately.
Collection of Past-Due Accounts
We make every effort to keep accounts from falling behind, and are willing to work with every individual in order to avoid the use of third-party collection specialists. If we must retain an attorney or collection company, the patient and/or guardian is responsible for all costs incurred with this process, including the attorney’s fee, court costs, and filing fees. Accounts that are 90 days past due will be assessed a 3% per month service charge.
Informed Consent/Consent to Treat
I have been informed of the nature, purpose and scope of care to be provided by Dr. Ernest W. Ferrel, D.C., the possible limitations and consequences of that care, and the possibility that the care given by Dr. Ferrel may not completely resolve my complaint, dysfunction or condition. I consent to care and recommendations made by Dr. Ferrel for myself (or my children, if minors) including, but not limited to examinations, x-rays, chiropractic adjustments, adjunctive therapies and rehabilitation. I understand that my care will be individualized and therefore may not be comparable with standards or guidelines required by insurance companies, Medicare, professional associations and/or consensus groups. I understand that my treatment will comply with the standard of care defined by the laws in the State of California. I recognize that all health care procedures, including those used in this office, have risks associated with them. Risks, although rare, associated with chiropractic adjusting procedures may include minor aggravation of symptoms, musculoskeletal sprain/strain, neurological deficits, osseous fracture, vertebral artery syndrome, including cerebrovascular accident (stroke) or death through complicating factors. I hereby accept the risks associated with any care by Dr. Ferrel of Ferrel’s Chiropractic and release Ferrel's Chiropractic of any liability for any injury or loss directly related to care I have received at this clinic.
Statement of Acknowledgement of Financial Responsibility
I understand that I may be responsible for any charges incurred at this office, including co-pays, deductibles, and any services denied or not covered by my insurance company. I realize my care may be subject to pre-authorization by the insurance company, and I accept any responsibility for charges not approved. The insurance company will review any/all documentation submitted by Ferrel’s Chiropractic for their assessment of medical necessity and base their approval/denial upon this documentation.
I understand that this office agrees to notify me as soon as possible if a service is not covered and will notify me if my insurance company does not approve my care. If a treatment plan is approved, this office will make me aware of the number of office visits allowed and the time frame of the authorization. Initial visits may be denied and this may be beyond the office’s ability to notify the patient prior to rendering acute care, while waiting for insurance coverage approval. These charges will be the patients’ responsibility if denied by the insurance company.
This office may seek payment from myself for any services my health insurance determines to be not medically necessary or not covered by my plan. Signing below indicates that I have read and understand my obligations for payment for care in the absence of insurance coverage.
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