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This is a copy of the information we give our client when they come in for an appointment. You can download the PDF and print it out. This information is including with patient information package.

Fill in the questions and sign the document and bring it with you to your appointment. This is the short insurance form. You can download the long form here.

Insurance: Informed Consent

Insurance is billed as a courtesy for our clients. We employ an insurance billing agency to submit our claims to the insurance company.

The average insurance bill for the average visit for therapy is $125.00. __________

The average cash payment per visit for a patient is $75.00, but sometimes higher. _________

This is because we have to use billing codes instead of fees per service or amount of time.

If the client prefers they may pay our standard fees for therapy by cash or credit card. We will give the client a receipt that they can turn into the insurance company. We reserve the right to have a sliding scale for clients of differing socioeconomic backgrounds. We reserve the right to offer cash discounts or issue discount coupons. We reserve the right to offer services on a donation basis for those in need or to donate our services to charitable events.

You can read a more in depth version of this Insurance Informed Consent by downloading it from our web site, or we can print it for you at our office. (www.healingwatersclinic.com/patientinfo.html)

Your responsibility: You, the patient, are responsible for all bills and fees that result from treatment regardless of whether the insurance company pays or not. __________

The patient is legally responsible for any bills generated during treatment and handled by their lawyer including PIP (car accidents) and Letters of Protection. While there may be negotiation for reduction of bills with the patient’s lawyer after a settlement, the patient is legally responsible for paying all bills. If insurance checks are mailed to the patient’s home, they must be turned over to us, the provider, or returned to the Insurance Company.

If the patient, a patient’s family member, or an acquaintance attempts to keep money from Insurance payments by cashing checks we will consider such actions fraud and notify the Insurance Company and turn the client over to appropriate law enforcement authorities. If the checks are stolen and cashed or `forged,’ or any other situation arises where money goes missing, the patient is still required to pay their bills. If the patient does not pay their bills, they can be turned over to a collection agency or taken to court.

We encourage the client to review Explanations of Benefits (EOBs) that are mailed to them from the insurance company. This will inform you as to what your insurance company is being billed by our insurance billing service. We will be glad to discuss and explain any charges. I have read and understand this Informed Consent thoroughly.

You can download the patient package here.

Click to see the Herbal Healing: Informed Consent

Click here to see the Notice of Privacy Practices

These forms are included with the patient package download