Intake Forms

Downloadable forms allow you to fill-out initial paperwork in the convience of your own home and at your own pace.

  • Forms will allow you to edit online.
  • Forms do not transmit data.
  • To save your information, save file to your computer.

FINANCIAL POLICIES _

1) Unless prior arrangement is made, full payment is due at the time of service.

Your payment options are: cash, check, or credit cards.

2) Insurance Billing

o If you would like us to bill your insurance, we will contact your insurer(s) and bill them based upon the non-guaranteed information they provide to us.
o You are responsible for all co-payments, deductibles and other adjustments made by your insurer(s).
o If we are unable to obtain a verification of benefits from your insurer for any reason, we will require full payment at the date and time of service.
o Insurance companies may reimburse differently than the information they initially provide to us.
o You are responsible for and will be billed for any resulting unpaid balance.

3) Discounts

We offer the following cash discounts. Only one discount may be applied to a bill.

o “Time of Service Discount” If you are paying in full for a treatment at the time of service, you will receive a 5% discount on Acupuncture services. This discount does not apply to co-payments, products, individual payment plans, or services other than those listed above.
o “Time Of Service Student Discount” Students, currently enrolled in accredited academic programs, will receive a 20% discount on all services if they pay in full at the time of service.

4) Missed Appointments/Late Cancellations

All appointment cancellations must occur within 24 hours of the appointment. If it is less than 24 hours, you will be charged $25 for the missed appointment.

5) Past Due Accounts

Accounts greater than 30 days past due will be charge a $10 administrative fee. Accounts greater than 90 days overdue will be sent to a collections agency.

These policies are subject to change without notice.