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Financial Agreement-All Patients

801 Franklin Avenue
Franklin Lakes, N.J. 07417
(201) 891-5599

Financial Agreement-All Patients

Dear Patient:
We have attempted to provide you with the necessary information to determine the type of care you require, and also the financial information you may need to determine how you wish to handle your financial obligation to the Chiropractic Family and Sports Injury Center.

We wish to make it very clear that your health is the sole responsibility of you, the patient, or your guardian.

These policies apply only to the services actually performed, and in no way obligates the patient to continue the source of treatment. If care is discontinued, the balance due for care received up to that date is due in full within 30 days of the discontinuance of care.

I have elected to use the following payment plan to finance my care at the Chiropractic Family and Sports Injury Center.

_______1. Cash- Payment is due at the time of services.

_______2. Medicare - Payment is due at the time of service. Chiropractic
Family and Sports Injury Center will complete all necessary
Medicare forms on my behalf.

_______3. Workers Compensation- My employer has agreed to pay for the
Services rendered by this office. I understand that I am responsible for any
portion of this bill that my employer or his insurance carriers may refuse to pay.

________4. Personal Injury- We will bill the insurance company and/or the lawyer
for personal injury. Should the claim be rejected, the balance is the
responsibility of the patient.

________5. Insurance Policy Coverage-Although I am totally responsible for the
charges I may incure in this office, I will initially pay for my yearly
deductible and the percentage agreed upon at the time of each visit
unless my insurance fails to pay its share, at which time I will pay my
balance in full.

*NOTE: Chiropractic Family and Sports Injury Center will refund any overpayments made to us upon completion of care.

DATE_____________ PATIENT_____________________________