LionsGate Chiropractic Confidential Intake Form

Patient Information:

Insurance Information:

LionsGate Chiropractic Authorizations & Financial Agreement

Financial Responsibility
By signing this agreement, you acknowledge that you are financially responsible for all services provided by Lionsgate Chiropractic. This includes charges for treatments, exams, and any other services rendered, regardless of insurance coverage.

1. Insurance Billing and Coverage
   • Verification of Benefits: Our office will assist in verifying insurance benefits; however, verification is not a guarantee of coverage. You are ultimately responsible for confirming the benefits and coverage with your insurance provider.
   • Assignment of Benefits: I authorize release of any medical information necessary to process claim/s and request payment of insurance benefits either to myself and/or the party who accepts assignment. I authorize medical benefit from third parties for benefits submitted for my claim/s to be paid directly to this office and any sum I now or hereafter owe this office by my attorney, out of proceeds of any settlement of my case and by any insurance company contractually obligated to make payment to me or you based upon the charges submitted for products and services rendered.
   • I understand and agree that health and accident policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that this office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to this office will be credited to my account upon receipt. However, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for products or professional services rendered will be immediately due and payable.
   • Non-Covered Services: I understand that some services may not be covered by my insurance, and I am responsible for these charges.
2. Payment Policies
   • Co-pays and Deductibles: Co-pays, deductibles, and any known non-covered charges are due at the time of service.
   • Self-Pay: Patients without insurance coverage or those opting for self-pay agree to pay the full amount at the time of each visit, unless other arrangements are made.
   • Payment Methods: We accept cash, checks, and major credit/debit cards.
3. Missed Appointments and Late Cancellations
   If you need to cancel or reschedule an appointment, please notify us at least 24 hours in advance. Failure to do so may result in a missed appointment fee. This fee is the responsibility of the patient and cannot be billed to insurance.
4. Collections and Outstanding Balances
   Any balance unpaid after 90 days from the date of service is considered delinquent. Should your account become delinquent, Lionsgate Chiropractic reserves the right to use a collections agency, and you will be responsible for all collection fees, attorney fees, and other associated costs.
5. Returned Checks
   A fee will be applied to any returned checks. If payment issues persist, we reserve the right to require cash or credit card payments.
6. Refund Policy
   Refunds are available for pre-paid, unused services. No refunds will be provided for services already rendered.
7. Agreement and Consent
   By signing below, I acknowledge that I have read, understood, and agree to the terms of this Patient Financial Agreement. I accept financial responsibility for all services provided by Lionsgate Chiropractic.