Professional Counseling and Coaching Services

Patient information Form

What is your reason for seeing the Dr. today?

Payment

Payment is expected at the time of service, with the exception of worker's compensation & automobile accidents. We will be happy to bill your insurance co. on a one-time basis per visit. It is your responsibility to provide this office with all necessary insurance information. I clearly understand and agree that payment for all services rendered to me are my responsibility. In the event of default, I promise to pay all collection and legal costs, as may be required to effect collection. Please do not hesitate to request a payment plan. 

I certify that the above information is complete and accurate to the best of my knowledge. I agree to notify this provider immediately whenever changes In my health condition or health plan coverage in the future.

• PAYMENT lS EXPECTED AT TIME OF SERVlCE.
• WE WILL BE HAPPY TO BILL YOUR INSURANCE COMPANY ON A VISIT BY VISIT BASlS, HOWEVER IT IS YOUR RESPONSIBILITY TO MAKE SURE WE HAVE CURRENT INFORMATION NECESSARY FOR BILLING. IF IT IS NOT PROVlDED AND VERIFIED PFllOFl TO YOUR APPOINTMENT PAYMENT WILL BE YOUR RESPONSIBILITY.
• IT IS ALWAYS THE PATIENT‘S RESPONSIBILITY TO VERIFY INSURANCE COVERAGE AND TO VERIFY NATUROPATHIC MEDICINE IS A BENEFIT OF THEIR COVERAGE PRIOR TO ANY APPOINTMENTS IN THIS OFFICE.
• IF COVERAGE IS DENIED FOR ANY REASON THE BALANCE WILL BE TRANSFERRED TO PATlENT RESPONSIBILITY AND DUE IMMEDIATELY.
• ALL COVPAYMENTS ARE DUE AT THE TIME OF SERVICE
• SOME SERVlCES AND ALL PRODUCTS ARE NOT COVERED BY INSURANCE AND ARE PATIENT RESPONSIBILITY TO BE PAID AT THE TIME OF SERVICE OR PICKUP.
• IF INSURANCE COVERAGE HAS BEEN VERIFIED BEFORE YOUR APPOINTMENT WE WiLL MAKE ARRANGEMENTS ON A CASE BY CASE BASIS TO DEFEH THE PROJECTED INSURANCE PORTION OF PAYMENT FOR 30 DAYS.
• THERE IS A $5.00 PER MONTH CHARGE FOR ANY BALANCE REMAINING ON ACCOUNT. 
• UNPAID ACCOUNTS WILL BE ACCESSED A $50.00 FEE IN ADDITION TO THE $5.00 MONTHLY CHARGE EVERY 6 MONTHS. 
• THE CLINIC OF NATURAL MEDICINE AND RESEARCH OFFERS A DISCOUNT TO UNINSURED PATIENTS AND PATIENTS WHO DO NOT HAVE NATUROPATHIC BENEFITS THIS BENEFlT DOES NOT APPLY TO PATIENTS WITH lNSURANCE.
• IF YOU WOULD LIKE TO BILL YOUR OWN INSURANCE WE ARE MORE THAN HAPPY TO PROVIDE YOU WITH THE APPROPRIATE DOCUMENTATION HOWEVER IT IS YOUR RESPONSIBILITY TO PAY YOUR BALANCE IN FULL ONLY UNINSURED PATIENTS ARE ELEGIBLE FOR TIME OF SERVICE DISCOUNTS.
• APPOINTMENTS CANCELED WITH LESS THAN 24 HOURS NOTICE OR NO SHOWED APPOINTMENTS WlLL BE ACCESSED A $25.00 FEE. THIS FEE MUST BE PAID PRIOR TO OR AT THE TIME OF YOUR NEXT APPOINTMENT PLEASE KEEP YOUR APPOINTMENT REMINDER CARDS THEY ARE YOUR PROOF OF SCHEDULED APP0INTMENTS

I understand and agree to the above terms. In the event of insurance denial or unpaid balances, I promise to pay & collection and legal costs necessary for debt collection in connection to services provided by The Clinic of Natural Medicine & Research. I also understand that The Clinic of Natural Medicine & Research will make every effort to assist me with special payment arrangements E I initiate and request special arrangements, make a good faith effort to stay in contact, provide updated contact information, and keep agreed upon payment arrangements.