JANWAY CHIROPRACTIC

BILLING/INSURANCE INFORMATION 

This office will file on almost any insurance; however, we are not responsible for what your insurance may or may not pay.  We will clarify any of our charges billed to your insurance.  Insurance denials will need to be resolved through your insurance company.

Please instruct your insurance company to issue and mail check to Janway Chiropractic clinic, PO Box 337, Muskogee OK 74402.  THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER MY INSURANCE POLICY.  Should insurance payment exceed your indebtedness, the balance will be refunded by the clinic.  Upon receipt by policyholder of a check for services to the clinic, policyholder should verify the status of any unpaid balance.

Accounts paid on date of service will receive time of service discount.  Should you have an outstanding balance, (cash- pay patient, no payment from insurance, denied for non-covered services, co-pay, etc.) you will be billed for these charges.   Accounts not paid in full within 30 days, with no prior payment arrangements, will be assessed a $5.00 monthly  fee.  A $10.00 service charge will be assessed on accounts with no payment activity within 30 days.  An account 60 days in arrears could be referred, at our discretion, for legal action; and any additional expenses incurred will become the responsibility of the patient

A photocopy of this assignment shall be considered as effective as the original.

I authorize the release of any information pertinent to my case to my insurance company.  I also authorize the doctor to initiate a complaint to the Insurance Commissioner for any reason on my behalf.

I AUTHORIZE DR JANWAY’S OFFICE TO LEAVE MESSAGES ON MY ANSWERING DEVICE.

I have read and understand these Billing/Insurance Policies

X________________________________________       
Signature of Patient/Policyholder 

X________________________________________ 
Signature of parent (if minor)

X________________________________________
Signature of Claimant (if other  than  policyholder)

 Mail this post