The patient will pay for the services received at the end of each office visit by either cash, check, or credit/debit card. I acknowledge there will be a $30.00 service charge for any dishonored checks.

The patient will pay their co-pay or deductible at the time of service by either cash, check, or credit/debit card. All other charges will be submitted to their perspective insurance carrier for payment. After remittance or denial is received, any unpaid balance will then be billed to the patient. Any unpaid balance beyond 30 days may be subject to a 1.5% monthly finance charge. I also acknowledge there will be a $30.00 service charge for any dishonored checks.

Chiropractic adjustments are generally considered safe; however, as with any healthcare procedure, there are potential risks. Some patients may experience temporary soreness, stiffness, muscle tenderness, fatigue, headache, or mild discomfort following treatment. Less commonly, symptoms such as dizziness, sprain or strain of muscles or ligaments, or aggravation of a pre-existing condition may occur. Serious complications are rare but can include fracture, disc injury, nerve irritation or injury, or, in extremely rare cases, stroke associated with neck manipulation. The chiropractor will evaluate your condition and discuss any concerns or questions you may have before treatment.

A. I hereby authorize release of any medical information necessary to process this claim and request payment of insurance benefits either to myself or to the party who accepts assignment.

B. I authorize payment of any medical benefit from third-parties for benefits submitted for my claim to be paid directly to this office. I understand payment to this office of 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.

C. I understand and understand that health care 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.

We have a Notice of Privacy of ProHealth Chiropractic Wellness Centers, PA available at the front desk at our office. This describes the Practice's policies and procedures regarding the use and disclosure of any of your Protected Health Information created, received or maintained by the Practice.