YOUR COMPANY NAME HERE
My First Visit
Your first visit to Aligned Health Chiropractic & Wellness Center will give you an opportunity
to find out if chiropractic care can help you. You will receive a thorough case history and
examination to make sure that your condition can be helped through the natural healing of
chiropractic adjustments.
As a doctor of chiropractic, Dr. Herta believes in natural healing, including chiropractic
treatments, rehabilitation, therapy, and nutrition.
On your initial visit the doctor will provide a consultation which will allow Dr. Herta to decide
if she feels that you could benefit from chiropractic care. She will do a complete health
history, examination and x-rays (if needed).
The doctor will review your findings in great detail and on the following day present to you
her findings and proposed schedule of care. You will begin your adjustments on that day
and any therapy treatments that your condition would necessitate.
GROUP OR INDIVIDUAL INSURANCE
We attempt to take out as much of the "insurance hassle" as possible for you. We'll happily
telephone your insurance company to verify your coverage benefits. Please remember,
however, that the benefits quoted to us by your insurance company are not a guarantee of
payment. We will file your claim and await payment for 90 days. If your company pays the
benefits they quote to us, the only services you will be responsible for are any non-
covered services, deductibles or co-pays. If you have any questions at all regarding you
financial responsibilities at our office, please do not hesitate to ask. Our insurance clerk
has years of experience and will be happy to assist you.
PATIENTS WITHOUT INSURANCE
An increasing number of patients do not have insurance, or have plans with limited
coverage, such as catastrophic policies. We realize that no one wants to build up a large
bill. Therefore, we have several plans so those patients may receive complete care without
undue financial difficulty. Of course we are always happy to accept cash, personal checks,
MasterCard, Visa or American Express.
"ON THE JOB" INJURY (Worker’s Compensation)
If you are injured on the job, your care should be paid for under your employer’s Worker’s
Compensation insurance. You will need to inform your employer of the accident and obtain
the name and address of the carrier of their insurance. If your employer does not provide
us with this information, if a settlement has not been made within 3 months, or if you
suspend or terminate care, any fees and services are due immediately.
PERSONAL INJURY OR AUTOMOBILE ACCIDENTS
Please notify your auto insurance carrier of your visit to our office immediately. Notify our
insurance department immediately if an attorney is representing you. Although you are
ultimately responsible for your bill, we will wait for settlement of your claim for up to six
months after your care is completed. Once the claim is settled or if you suspend or
terminate care, any fees for services are due immediately.
MEDICARE
We do accept assignment from Medicare. The check is usually sent directly to our office in
payment of the services that Medicare will cover, which for Chiropractors is ONLY manual
manipulation of the spine. Medicare pays 80% of the allowable fee once the deductible has
been met. You are required to pay the deductible and the remaining 20% as well as any
non-covered services. Our office completes and files the forms for Medicare at no charge.
SECONDARY INSURANCE
Please inform us of any secondary insurance you may have.
Patient Forms
Chiropractic Case History/Patient Information
Insurance Form
Informed Consent
Your first visit to Aligned Health Chiropractic & Wellness Center will give you an opportunity
to find out if chiropractic care can help you. You will receive a thorough case history and
examination to make sure that your condition can be helped through the natural healing of
chiropractic adjustments.
As a doctor of chiropractic, Dr. Herta believes in natural healing, including chiropractic
treatments, rehabilitation, therapy, and nutrition.
On your initial visit the doctor will provide a consultation which will allow Dr. Herta to decide
if she feels that you could benefit from chiropractic care. She will do a complete health
history, examination and x-rays (if needed).
The doctor will review your findings in great detail and on the following day present to you
her findings and proposed schedule of care. You will begin your adjustments on that day
and any therapy treatments that your condition would necessitate.
GROUP OR INDIVIDUAL INSURANCE
We attempt to take out as much of the "insurance hassle" as possible for you. We'll happily
telephone your insurance company to verify your coverage benefits. Please remember,
however, that the benefits quoted to us by your insurance company are not a guarantee of
payment. We will file your claim and await payment for 90 days. If your company pays the
benefits they quote to us, the only services you will be responsible for are any non-
covered services, deductibles or co-pays. If you have any questions at all regarding you
financial responsibilities at our office, please do not hesitate to ask. Our insurance clerk
has years of experience and will be happy to assist you.
PATIENTS WITHOUT INSURANCE
An increasing number of patients do not have insurance, or have plans with limited
coverage, such as catastrophic policies. We realize that no one wants to build up a large
bill. Therefore, we have several plans so those patients may receive complete care without
undue financial difficulty. Of course we are always happy to accept cash, personal checks,
MasterCard, Visa or American Express.
"ON THE JOB" INJURY (Worker’s Compensation)
If you are injured on the job, your care should be paid for under your employer’s Worker’s
Compensation insurance. You will need to inform your employer of the accident and obtain
the name and address of the carrier of their insurance. If your employer does not provide
us with this information, if a settlement has not been made within 3 months, or if you
suspend or terminate care, any fees and services are due immediately.
PERSONAL INJURY OR AUTOMOBILE ACCIDENTS
Please notify your auto insurance carrier of your visit to our office immediately. Notify our
insurance department immediately if an attorney is representing you. Although you are
ultimately responsible for your bill, we will wait for settlement of your claim for up to six
months after your care is completed. Once the claim is settled or if you suspend or
terminate care, any fees for services are due immediately.
MEDICARE
We do accept assignment from Medicare. The check is usually sent directly to our office in
payment of the services that Medicare will cover, which for Chiropractors is ONLY manual
manipulation of the spine. Medicare pays 80% of the allowable fee once the deductible has
been met. You are required to pay the deductible and the remaining 20% as well as any
non-covered services. Our office completes and files the forms for Medicare at no charge.
SECONDARY INSURANCE
Please inform us of any secondary insurance you may have.
Patient Forms
Chiropractic Case History/Patient Information
Insurance Form
Informed Consent
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