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Century Chiropractic & Acupuncture Clinic

FINANCIAL POLICY

Thank you for choosing us as your health care provider. Our goal is to provide you with quality medical care. To make our services available to as many patients as possible on an affordable basis, we have adopted the collection policy outlined below. We ask you to read the policy carefully and sign prior to any treatment.

FULL PAYMENT IS DUE AT TIME OF SERVICE
WE MAY ACCEPT ANY ASSIGNABLE INSURANCE WITH APPLICABLE COVERAGE.
WE OFFER AN EXTENDED PAYMENT PLAN WITH PRIOR CREDIT APPROVAL.
WE ACCEPT CASH, CHECKS, OR VISA/MASTERCARD, DISCOVER & AMERICAN EXPRESS CARD.

Dishonored checks will be charged back to the patient's account with a service fee of $25.00. Dishonored checks not redeemed within 20 working days of written notice to the maker will be referred to the prosecutor for collection.

Regarding Insurance

We may accept assignment of insurance benefits at our discretion if acceptable insurance identification is provided. Acceptable insurance identification is defined as a valid insurance card, policy/plan with applicable coverage, or telephone verification. As a courtesy to our patients, verifiable and assignable insurance will be billed by this clinic. However, you will be personally responsible for your account balance regardless whether or not if your insurance will pay for your total balance of your claims. Your insurance policy/employee benefits plan is a contract between you and your insurance company/employee benefits plan. We are not a party to that contract. In the event we do accept assignment of benefits we require that you be pre-approved on our extended payment plan BY PROVIDING A CREDIT CARD (see below) OR PERSONAL CHECKING ACCOUNT WITH AUTHORIZATION (see below) TO CHARGE THAT AMOUNT FOR THE BALANCE DUE, if your insurance company/employee benefits plan has not paid your account in full within 45 days or has determined your claims to be your responsibility for the reasons of annual deductible, co-payment, non-covered services and not medically necessary.

         We have entered into a contractual arrangement with the following managed care networks. If you are a member of the following PPO networks, you may enjoy several benefits, such as PPO discounts, deferred payment obligation until you received your insurance explanation of benefits after PPO discounts. Please identify yourself with such PPO networks on your first visit. However you are required to pay whatever specified on your insurance card on each visit in accordance with our PPO agreements, and if your PPO payor fails to pay for your claims within 45 days or promptly in accordance with our PPO agreement, your PPO discounts will be invalidated. We are the PPO provider of the following networks:

        Blue Cross Blue Shield of Illinois (Provider #: 2206308)
        Private Health Care System (PHCS)
        Humana/Employers Health--ChoiceCare/PHCS

If a patient chooses or is required to bill his/her own insurance, this clinic will provide an itemized statement and a HCFA-1500 Form to the patient, but will treat the account as a self-pay.

If you have any questions regarding our financial policies, please do not hesitate to ask us at any time. We thank you for your co-operation.

I have read the Financial Policy. I understand and agree to this Financial Policy.

Date:	___________	Signature of Patient:	_________________________
Date:	___________	Signature of Guarantor:	_________________________

Century Chiropractic & Acupuncture Clinic

CREDIT CARD PREAUTHORIZATION FORM

       I authorized the Century Chiropractic & Acupuncture Clinic to keep my signature on file and to charge my Visa/MasterCard/Discover/American Express Card account for medical expenses incurred by me at this clinic.

      I understand that each charge incurred by me at this clinic has to be explained or disclosed to me and pre-authorized by me specifically in writing before the services are rendered.

   If I assign my insurance/employee health benefits to the provider listed above, I agree to be personally responsible for the total charges incurred by me regardless of any insurance denial and applicable insurance partial payments.

      I acknowledged that no guarantee or assurance has been given to me as to the results that may be obtained from the services rendered by this clinic. I understand that this form is valid for one-year unless I cancel the authorization through written notice to the above listed clinic and provider.

      I understand that the recurring charges to my credit card account will appear on my statement every month from this clinic. The amount charged to my account each month will vary dependable on my usage of medical services and will be consistent with my agreement now in effect with the above listed clinic and provider.

[ ]    Balance of charges not paid by insurance within 45 days and not to exceed $______ for:

   [ ]
This visit only.

[ ]
All visits this year.

[ ] Recurring charges (on-going treatments) of $_______ every_______ from__________

^(frequency)

^(date)

to_____________ until total balance is paidoff.

^(date)

Patient Name: _______________________________________________

Cardholder Name: _______________________________________________

Cardholder Address: _______________________________________________

City: _________________________ State:_______ Zip:________

Card Type: (VISA/MasterCard/Discover/American Express) ___________________

Account Number:
__________________________ Expiration Date:________

Cardholder Signature:
__________________________ Date: ________________

Century Chiropractic & Acupuncture Clinic

Pre-Authorized Debits Automatic Payment Agreement

     I authorize the Century Chiropractic & Acupuncture Clinic, hereinafter called CLINIC to draw checks to debit my checking account, indicated below and the Depositary Institution named below, hereinafter called BANK, to accept and to debit/credit the amount of such entries to my (our) account, for medical expenses incurred by me at this clinic.

     This authority is to remain in full force and effect until CLINIC and BANK have received written notification from me (or either of us) of its termination, and in no event shall it be effective with respect to entries originated by CLINIC prior to receipt of notice of termination.

       I (we) understand that paid drafts or transfer requests will be honored only if sufficient funds available in my (our) account.

       I understand that each charge incurred by me at this clinic has to be explained or disclosed to me and pre-authorized by me specifically in writing before the services are rendered. If I assign my insurance/employee health benefits to the provider listed above, I agree to be personally responsible for the total charges incurred by me regardless of any insurance denial and applicable insurance partial payments. I acknowledge that no guarantee or assurance has been given to me as to the results that may be obtained from the services rendered by this clinic.

       I understand that the recurring charges to my checking account will appear on my statement every month from the Clinic. The amount charged to my account each month will vary dependable on my usage of medical services and will be consistent with my agreement now in effect with the above listed clinic and provider.

[ ] Balance of charges not paid by insurance within 45 days and not to exceed $______ for:

[ ]	This visit only.
[ ]	All visits this year.

[ ] Recurring charges (on-going treatments) of $_______		every_______	from__________
		^(frequency)	^(date)
to_____________	until total balance is paidoff.
^(date)

AUTHORIZATION TO HONOR CHECKS
Name of Depositor:
_________________________________________		____________________
^{(Name as Shown on Account, Print as it appears on Bank Records)}		^{(Account or Code Numb}^er)
To:	_____________________________________	____________________
	^{(Name of Bank Institution)}	^{(Branch Names)}
	_____________________________________	____________________
	^{(Address of Bank Institution or Branch where account is maintained)}	^{(Bank Telephone Number)}

(Note: Attach a Voided Blank Check to Ensure Accuracy)

As a convenience to me I authorize you to pay and charge to my account check(s) to the order of the CLINIC listed above.

I agree that your treatment of each check and your rights with respect to it, will be the same as if it were signed or initiated personally by me. I further agree that if any check is dishonored for any reason, you will not be under any liability even though dishonor results possible breach of my agreement with the CLINIC listed above. I further agree that this authorization is to remain in effect until you receive written notice from me of its revocation unless you end it earlier.

Date:

___________

Signature of Patient:

_________________________

Date:

___________

Signature of Depositor:

_________________________

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