OFFICE POLICY and FINANCIAL AGREEMENT

• I will be on time for my appointments. If I need to cancel or reschedule, I will notify Crown Hill Chiropractic as soon as possible.

• I will avoid wearing strong perfumes or colognes in consideration of other patients with allergies or respiratory problems.

• Children are welcome at Crown Hill Chiropractic, both as patients and guests. If I bring children to an appointment, I will be responsible for their actions at all times.

• I will notify Dr. Kevin of any changes in my health status, regardless of significance.

• Payment is due at the time of service. Crown Hill Chiropractic accepts credit cards, debit cards, cash, and personal checks.

• The office manager may approve a payment plan for account balances.

• An insurance contract is between my insurance company and me. My insurance company determines benefits when it receives billings from Crown Hill Chiropractic. If there are any problems, I may file a grievance directly with my insurance company.

• I understand and agree that any unpaid balances not covered by my insurance will be paid by me. I am always responsible for the payment of my care.

• Any statements made by Crown Hill Chiropractic staff regarding my insurance benefits in no way guarantee coverage by my insurance.

• I specifically authorize and assign Crown Hill Chiropractic to the collection of insurance benefits and release of daily chart notes when necessary for the processing of claims.