Thank you for choosing Pokey Practice Acupuncture as your healthcare provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered part of your treatment. The following is a statement of our financial policy, which we require you to read and sign prior to any treatment.
Our fees are determined by the complexity of each case and different services used.
- Pokey Practice Acupuncture requires coverage verification prior to treatment and we will file all claims as a courtesy to you.
- If for any reason we are not able to verify coverage prior to your treatment, you will be charged for the treatment until verification is obtained.
- We cannot bill your insurance unless you bring us all necessary insurance information.
- We are not a party to that contract.
- By recieving treatiment and reading this document, you are assigning to this office the benefits to which you are eligible to receive for care rendered in this office.
- Additionally, in reading and signing this document you authorize the release of any information to any insurance company, adjuster or attorney that will assist in the payment of a claim.
- We request a credit card on file if the insurance company should not pay claims or any balances owed should there be any difference in the amount owed.
Usual and Customary Rates UCR:
- Our practice is committed to providing the best treatment possible for our patients.
- We charge what is usual and customary for our area.
- Please be aware that some and at times perhaps all of the services may be non-covered services and not considered reasonable and necessary by medical insurance.
- All payments are due at the time of service.
- Unless cancelled at least 24 hours in advance, our policy is to charge the full fee for missed appointments at a cost of the full time of service private pay office visit you are booked for if you are a repeat offender of this rule.
- Your treatments will be more effective if you follow your provider's guidelines and stick to your treatment schedule.
- Please help us to serve you better by keeping your scheduled appointments.
- Please let us know if you have any questions or concerns.
- By agreeing to receive treatment in Pokey Practice Acupuncture's Broomfield Acupuncture Clinic you agree to this financial policy.
- There are two billing options available for you.
- Please select the one you prefer us to use for your visits.
- If at any time if you choose to change your billing option, you are required to let us know immediately and sign a new Office Financial Policy and Authorization to Bill Insurance Form.
- Private Pay patients are patients that do not bill insurance.
- This discounted cash rate is only applied to the published rate if you pay at the time of service.
- In reading this policy you understand that you must pay all co-payments and/or co-insurances not covered by your insurance company at the time of check in for any and all visits.
- Pokey Practice Acupuncture will submit your claim for you to your insurance company.
- Although Pokey Practice Acupuncture verifies your insurance, you understand that this verification is not a guarantee of payment.
- You understand that any and all charges incurred at this office including co-payment, co-insurance, percentage due and/or deductibles or any other fees or services not covered by your insurance company are your responsibility.
- You also understand that if these patient portions due are not paid at the time of service you will be subject to a $10.00 billing fee per month.
- You also understand that there will be no exceptions to this monthly billing fee until the outstanding amounts are paid.
- Payments more than 30 days delinquent will result in temporary suspension of care unless other arrangements are made.
- You further understand that any unpaid balance over 90 days, can and will be sent to collections for recovery unless prior arrangements have been made.
- By reading this you authorize your insurance benefits to be paid directly to Pokey Practice Acupuncture.
- You also authorize your provider(s) to release any information and medical records required by your insurance company.
- You also understand that you may revoke this consent by written request, at any time.
- No other records or information about you shall be released without your signed consent at any time.