Fees, Insurance and Payment Agreement ‘The fees charged inthis office are comparable t those charged by ther specialists with similar qualification inthis geographic area. ‘These foes for office services are payable at the ime of visit, except in cases enumerated below. For your convenience we Accept cash, checks, Visa, MasterCard and American Express, {you carry health insurance covering any service that we offer, it i your responsibility o provide us with the proper insurance identification cand showing proof of coverage on your first visit and provide us with a copy of your card if your coverage changes daring your treatment inthis office, Ifyou area patient of an indusrial accident, you must provide us with an authorization signed by your empleyer or supervisor ‘authorizing the doctor to provide medical services to you on your fits visit. You must also provide us with the name, address ‘and phone number of the worker's compensation carrier Ifyou have private heath insurance coverage, pleas be sre tha! your portion ofthe insurance form is carefully completed and signed. We urge you to carefully review your insurance coverage prior your office vist, you are responsible forall dodveti bles, co-insuranees, co-payments at the time services are rendered. Please undersiané that we do not participate with the majority of commercial insurance caries due to low reimbursement rates. However, all serves rendered in this office are payable by You unless other arrangements are agreed upon, Should there be a balance due on your account, we reserve the right to make the finarcial charge al an interest rate of 1.5% per moth for every month that your account remains overdue after 30 days. {you agree tothe above terms please sign at the space provided below 24 HOURS NOTICE IS REQUIRED IF YOU CANNOT MAKE YOUR APPOINTMENT, OTHERWISE YOU ARERE- ‘SPONSIBLE FOR THE FULL PAYMENT OF THE MISSED APPOINTMENT. T = ool een seas sala | Office Vist - initial - Brief ge201 | s ‘Acupuncture Initial 1 Minutes 97810 | $ | omega) Se [Tu epee Ea | Offce Vie - nt -Itemedite ox20e | s Elecro-Acupunctue intial 18Mirutes | 97819 | $ Electro-Acopunature Adeltonal 15 (Offce Vist ital - Extends eao4 | s Minutes srara| § Oftce Vist -Intial-Comprenersive | e205 | $ (fice Viet Estebined- Bit saan | s cupping 5 (fice Viet tabi Limite oor | s birered therapy srozs| § Office Vist-Estabished-inermedate | 90213 | s Missed Offoe Viet e040 | § Ofice Vist -Established-Extendes | aria | § Electric Strulation (Unattended) | a7ore | ‘Ofice Vist - Established Comprehan- sie ois | s ‘Therapeutic Exeriees oro | s ‘Alter Hours Services e050 | $ Additional Area erst | s Maral Therapy (Tana) (eit HomeCare soos | s our) erro | ¢ Het Cola Packs e710 | s Massage Therapy tial hour) | 97124 | $ Date: Patient Signature