In compliance with Federal and State Consumer Protection and Informed Consent Laws, we present the following basic outline of usual and customary procedure and fees.
Examination/Evaluation (If Necessary) $45-$140
Graston (If Necessary) $35
Each Therapy (If Necessary) $10-$50
Spinal Adjustment (If Necessary) $38-$58
Kinetic Activity (If Necessary) $38
IF NO INSURANCE: Payment is due when the service is rendered. We gladly accept cash, check, Debit Card, Visa, MasterCard, or Discover. No more than three payment installments shall be allowed if not on auto-debit plan.
INSURANCE: Please pay your co-insurance of your charges on your first visit. After we receive payment from your insurance company, we will bill you for any balance due. Any procedures not covered by your insurance will have to be paid by you at the time of service. If you fail to keep your scheduled appointments or if you discontinue care for any reason other than discharge by the doctor the bill is due and payable in full immediately, regardless of any insurance claims submitted.
MEDICARE/MEDICAID: Medicare insurance covers adjustments by the chiropractor. Medicaid covers chiropractic adjustments along with a $1 co-pay per visit (when applicable).
Advance Beneficiary Notice of Non-coverage: Note Medicare / Medicaid do not pay for everything, even some care that you or your health-care provider have good reason to think you need. Medicare and Medicaid typically only pay for spinal adjustments in a chiropractic office; therefore if your insurance does not pay for the care, you may have to pay. This notice gives our opinion, and is not an official Medicare/Medicaid decision. If you have questions on this notice you may call Medicare 1-800-633-4227 or your Medicaid carrier.
INTEREST CHARGES: Interest will be charged to all delinquent accounts. Any cost to collect said delinquent accounts will be your responsibility. Campbell Chiropractic Clinic, P.C. reserves the right to charge an additional fee for collection of delinquent accounts.
ASSIGNMENT OF RIGHT TO PAYMENT/LIEN AGAINST BENEFITS: I hereby authorize Campbell Chiropractic Clinic, P.C. to file my claim. I assign to them my right to receive any and all payments or recoveries from any insurance company, attorney, or third party for professional services rendered by Campbell Chiropractic Clinic, P.C. I convey a lien against any funds and authorize and direct any third party to withhold sum from any benefits, judgments, verdict, settlements, or recoveries, and to adequately protect and to make payment for these services directly to Campbell Chiropractic Clinic, P.C. pursuant to this assignment and lien.
ASSIGNMENT OF CAUSE OF ACTION: In the event that any insurance company or other third party obligated to make payment to me or to Campbell Chiropractic Clinic, P.C. for the charges made for services, refuses to make such payment upon demand, I hereby assign, transfer and convey to Campbell Chiropractic Clinic, P.C. any and all cause of action that might exist in my favor against any such company or person. I authorize Campbell Chiropractic Clinic, P.C., to prosecute said action either in my name or their name to collect fees due for care rendered and legal expenses and to resolve said claims as they see fit. In the event that it becomes necessary to retain an attorney, I agree that I am responsible for all court costs and attorney fees.
AUTHORIZATION TO PROCESS DRAFTS: I agree that Campbell Chiropractic Clinic, P.C. shall be appointed as my agent to endorse drafts or to sign my name on any checks for payment of my bill for medical services rendered.
VENUE: I agree that all charges are payable and collectable in Union County, South Dakota and that all provisions of this contract are to be performed in Union County. The invalidity or unenforceability of any provision hereof shall in no way affect the validity or enforceability of any other provision.
Signing below indicates that I understand this notice.