Acupuncture is a healing modality that involves the insertion of small, disposable needles in the skin. Risks of treatment include: bruising, small amounts of bleeding, fainting, possible aggravation of treated symptoms within 72 hours of treatment before clearing (i.e. “Law of Cure”), and in rare cases, pneumothorax. My practitioner has explained these risks to my satisfaction and I understand and am willing to undertake these risks as a part of acupuncture treatment.

We would like to welcome you to our office and assure you that you will receive the very best of care available for your condition. In order to familiarize you with the financial policy of this office we would like to explain how your medical bills will be handled.

Explanation of Insurance Coverage:
Many insurance policies do cover acupuncture care but this office makes no representation that yours does. Insurance policies may vary greatly in terms of deductible and percentage of coverage for acupuncture care. Because of the variance from one insurance policy to another, we require that you, the patient, be personally responsible for the payment of your deductibles, as well as any unpaid balances in this office. We will do our best to verify your insurance coverage and will bill your insurance in a timely manner.

Payment Arrangements
We require that you pay $30 towards today’s charges and $30 each visit, unless an Explanation of Benefits (EOB) from your insurance describes differently. Your full portion of the bill is expected to be due when payment is received from your insurance carrier. Any unpaid balances will be considered past due 30 days following insurance reimbursement. Past due balances will have an interest charge of 2.5% applied per month.
Financial Responsibility
All professional services rendered are charged to the patient and are due at the time of service,
unless other arrangements have been made in advance with our business office. Necessary forms
will be completed to file for insurance carrier payments. If your insurance carrier sends payment to you for services incurred in this office, you agree to send or bring those payments to this office upon receipt.

Voluntary Termination of Care
If you suspend or terminate your care at any time, your portion of all charges for professional services is immediately due and payable to this office. This includes failure to complete a written treatment plan as well as multiple cancellations or no-shows to appointments. All services rendered by this office are charged directly to you, and you ultimately will be personally responsible for payment regardless of insurance coverage.

Late Cancellations and No-Shows
Late cancellations (within 24 hours of appointment time) and no-shows may incur a $25 fee per incident. No-shows may also lead to termination of your care or treatment plan, as this greatly interferes with the ability of the practitioner to provide quality care within the timeframe needed to achieve maximum therapeutic results. Late and no-show fees are payable prior to any future service. If not paid, care will be terminated and you will be referred to a list of local practitioners to continue care. Excessive late cancellations (more than three per calendar year) will lead to the practitioner only accepting appointments made the same day as requested.

Accepted Payment Types
This office accepts cash, personal check or credit cards for unpaid balances. Returned checks will add a $35 fee per check to your balance to recoup bank charges.

Assignment of Benefits
I hereby assign all medical and surgical benefits, to include major medical benefits to which I am entitled. I hereby authorize and direct my insurance carrier(s), including Medicare, private insurance and any other health/medical plan, to issue payment check(s) directly to Five Dances Acupuncture for medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by insurance.

Authorization to Release Information
I hereby authorize Five Dances Acupuncture/Samantha L. Francis to: (1) release any information necessary to insurance carriers regarding my illness and treatments; (2) process insurance claims generated in the course of examination or treatment; and (3) allow a photocopy of my signature to be used to process insurance claims for the period of lifetime. This order will remain in effect until revoked by me in writing.

I have requested medical services from Five Dances Acupuncture/Samantha L. Francis on behalf of myself and/or my dependents, and understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized.

I further understand that fees are due and payable on the date that services are rendered and agree to pay all such charges incurred in full immediately upon presentation of the appropriate statement. A photocopy of this assignment is to be considered as valid as the original.