Patient Forms

This form is in PDF format. Please click on the link and the form will download so you can print, fill out and bring into our office on your next visit.  

Financial Policy

Our goal is to make your care effective and affordable. We have several payment plans available for our patients with no or limited insurance coverage. Insurance payments for chiropractic care vary tremendously from insurance company to insurance company and even from policy to policy. We ask that you read and understand our policy as it applies to your particular situation.

PATIENTS WITHOUT INSURANCE OR
PATIENTS WITH INSURANCE THAT EXCLUDES CHIROPRACTIC

We request that 100% of the first visit be paid at the time of the visit. On other visits, payment may be made at the end of the week if you sign a credit guarantee form. We are happy to accept your check, Master Card, Visa, Discover and American Express. More than half of our patients pay for their care using our Healthcare Made Affordable Pre-Pay Plan and other Maintenance Care plans.

GROUP OR INDIVIDUAL INSURANCE

When possible, we will call to verify benefits on your insurance. However, the benefits quoted to us by your insurance company are not a guarantee of payment. Payment will be due by you at the time of service for any non-covered services, deductibles or co-pays.

MEDICARE

You can be confident we striclty adhere to Medicare's Allowable Charges for our "65 and Better" patients for all services in our office. Our office will complete and submit all Medicare forms at no charge to you.
We do not accept assignment, and you may pay at the time of service.
Medicare will pay 80% of the Allowable Charges on Manual Manipulation of the spine once the deductible has been met, and you will receive a check directly from Medicare. Maintenance care will not be reimbursed.

MANAGED CARE PLANS

We are providers for many managed care plans, including Blue Cross Blue Shield, Aetna, United Health Care, Humana, Principal Life, PHCS, and others. Please call our insurance department to find out if we are on your plan.

I have read and understand the payment policy of Georgetown Family Wellness. I understand that my insurance is an arrangement between myself and my insurance company, NOT between Georgetown Family Wellness and my insurance company. I request and instruct this office to prepare the customary forms at no charge so that I may obtain insurance benefits. I also understand that if my insurance does not respond within 60 days, or if I suspend or terminate my schedule of care as prescribed by the doctors at Georgetown Family Wellness that fees will be due and payable immediately.

__________________________________________ ________Date
Patient’s signature (or guardian if patient is a minor)

___________________________________________ _______ Date
GFW Representative

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