Have you seen any other providers for this condition?

Have you had any of the following conditions in the PAST?

Do you or any of your immediate family have any of the following?

Cuse Chiro Office Policy (Accept and Sign Below)

1. Insurance. This office operates as a Direct Primary Care facility, and as such, cannot participate with any insurance plans, including Medicare (see #2). If you choose to pay-as-you-go in a “Fee for service" manner, you can submit our bills to your insurance for reimbursement (see #3).
2. Medicare. This office does not participate with Medicare. Chiropractors are the only health profession that is not allowed to see Medicare beneficiaries if the provider doesn't participate with Medicare. Therefore, if this office is aware that you are a Medicare beneficiary, we are legally obligated to refer you to another chiropractic provider.
3. Claims Submissions.  This office will, at your request, provide any information you need to submit to your insurance.  For most cases, this requires a "Superbill", which can be generated at your request via email. It is your responsibility to comply with your insurance company's requests and requirements. Please be aware that the balance of your claim is your responsibility whether or not your insurance pays your claim. Your insurance benefits are a contract between you and your insurance company, we are not party to that contract.
4. FSA/HSA. This office accepts payments from FSA and HSA accounts. Should you require more information for reimbursement, please contact the office in writing and we will do our best to provide you with any information you need to be reimbursed.
5. Card Authorization.  Cuse Chiro uses an EHR system that automatically stores your credit card for future purchases, including missed appointments (#6) and/or late fees (#7).  Therefore, I, authorize Cuse Chiro, Inc to charge my credit card for any charges that have accrued on my account. I understand that my information will be saved on file for future transactions on my account.
6. Missed Appointments. Patients will be charged for missed appointments not cancelled 24 hours in advance.  The charge is equal to 50% of the office fee schedule. The charges will be your responsibility and will be charged directly to the card you have supplied (#5).
7. Late Fees.  In an effort to keep fees low, the office fee schedule reflects a "time of service" discount that is built in to the payments when paid during your visit.  If for some reason you do not pay for your services at the time of service and an invoice is sent out, the fees will be subject to a $5 "Time of Service" Fee per visit.  In addition, Invoices that remain delinquent at 30, 60, and 90 days will incur a 10% late fee and will continue to incur late fees until payment is made.  Failure to pay will result in submission of debt to debt collection (see #8).
8. Collections. Unpaid balances will be sent to collections. If your balance is sent to collections, you will be responsible for an additional 30 percent of the remaining balance to be added to the original amount sent to collections.

Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges of our area. Thank you for understanding our payment policy. Please let us know if you have questions or concerns.

Health Insurance Portability and Accountability Act (HIPAA) (Accept and Sign below)

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