This was shared by Dr. Ross: KRoss777@aol.com Fee Schedule ________________________________________________________________________ Full Fee Initial Consultation and Complete Chiropractic Examination $ 60.00 X-ray As Needed (cost is per view) $ 30.00 Chiropractic Adjustment $ 35.00 Our experience has shown that it is wise to have an understanding with our patients as to the office policies and fees. This form has been prepared for your convenience and information. We offer several methods of payment for your Chiropractic Care at our office, and you may choose the plan that best fits your needs. Please read carefully and choose the plan which you prefer. This information will enable us to better serve you and help to avoid misunderstandings in the future. If special arrangements are necessary, please consult with the Doctor or our Chiropractic Assistant. Our main concern is your health and well-being, and we will do our best to help you. PLAN # 1--INSURANCE--If you have insurance which covers chiropractic care, you will bill your insurance directly. We do not „accept assignment¾. This means all services are paid in full at the time of service and we provide a form for you to submit for reimbursement to offset the cost of your care. *ALL INSURANCE IS BILLED AT OUR FULL FEE FOR SERVICES RENDERED. *ANY REQUESTS FOR ADDITIONAL INFORMATION FROM AN INSURANCE COMPANY WILL BE COMPLETED BY OUR OFFICE FOR AN ADDITIONAL $25 FEE. Most insurance companies cover ONLY corrective care which is the treatment of a specific, acute problem/symptom/injury. Once you are placed on a maintenance schedule by the doctor, most insurance companies will no longer cover your care. This is because insurance companies are really only involved with "disease care" and NOT true "health care". At this point you would want to refer to our monthly family wellness plans (Ask at front desk for details.) PLAN # 2--CASH-- Fees are paid at the time of services rendered unless special arrangements are made in advance. IF PAYMENT IS MADE AT A DISCOUNTED FEE (LESS THAN "FULL FEE") IT CANNOT, AND WILL NOT, BE BILLED TO YOUR INSURANCE CARRIER. IF YOU DO, IT CONSTITUTES INSURANCE FRAUD.....IF YOU HAVE ANY QUESTIONS CONCERNING THIS MATTER PLEASE ASK THE DOCTOR. We will only provide a cash receipt for tax purposes. No diagnosis codes or procedure codes will be included. *PATIENTS WITH MEDICAL SAVINGS PLANS (AKA åFLEX PLANS¼) WILL ONLY BE PROVIDED A CASH RECEIPT ON OUR LETTERHEAD STATING AMOUNT OF PAYMENT AND DATE. PLAN # 3--CASH PRE-PAY--Special discounted fees are available to patients who are willing to commit the time to changing their health. Ask at front desk for details. PLAN # 4--INDUSTRIAL--You need to report your accident to your employer immediately. Bring in necessary insurance information and sign industrial forms for billing by second visit. We will bill your insurance directly at full office fee. PLAN # 5--AUTO INJURY--You need to supply us with the accident report, your car insurance, health insurance, liable parties insurance, and an attorney if applicable. Until all insurance information is gathered and verified for Chiropractic Care, you will be required to pay for your care. We bill insurance directly after verification of coverage at full office fee. Many insurance companies will make medical payments directly to the insured. SHOULD THE PAYMENT CHECK COME TO YOU, YOU ARE REQUIRED TO BRING THE CHECK TO THE OFFICE. PLAN # 6--FAMILY WELLNESS PLAN--TO QUALIFY FOR THIS: 1) You have been under regular, active chiropractic care up until this point (not necessarily in this office) and wish to continue a dedicated health-maintenance program. OR... 2) You would like all members of your family to be under chiropractic care and wish the benefits of the family discount to make it affordable. Ask at front desk for details. I WISH TO UTILIZE PLAN #_____________. I UNDERSTAND THE REQUIREMENTS FOR THAT PLAN. SIGNATURE________________________________________ DATE_____________________________