“Office Financial Policy in Laplace, LA - Attraction Wellness Center ”

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Office Financial Policy

Our policy is to extend to you the courtesy of allowing you to assign your insurance benefits directly to us. This policy reduces your out-of-pocket expense and allows you to place your family under care.

If You Do Not Have Insurance: All payments are expected at the time of service or by an authorized payment plan. Your personal balance may not exceed $100 at any time or care may be terminated. Our payment plans make care an affordable part of your family budget.
If You Have Insurance: All deductibles and co-payments are expected at the time of service or by an authorized payment plan. Your co-insurance balance may not exceed $100, or care may be terminated. Our payment plans make care an affordable part of your family budget.

You are considered a cash patient until you bring in your completed insurance forms, and we qualify and accept your insurance coverage. We do not accept assignment for secondary Insurance carriers, however, will be happy to provide you with a claim form for your secondary carrier.

Our fees are considered usual, customary and reasonable by most companies, therefore, covered up to the maximum allowance determined by each carrier. This statement does not apply to companies who reimburse based on an arbitrary schedule of fees being no relationship to the current standard and care in this area.

If your carrier has not paid a claim within sixty (60) days of submission, you agree to take an active part in the recovery of your claim. If your insurance carrier has not paid within ninety (90) days of submission, you accept responsibility for payment in full of any outstanding balance and authorize us to use your credit card to collect full payment.

When your schedule of visits is once per month or longer, you will not be eligible for insurance assignment. Charges for services rendered will be due as they are rendered.

If you discontinue care for any reason other than, discharge by the doctor, all balance will become immediately due and payable in full by you, regardless of any claim submitted.

Per our company policy, a $30 fee will be charged for all no-call, no-show appointments. Please notify us at least 24 hours in advance if you need to make to make any changes or cancel your appointment in order to avoid any cancellation fees.

Please indicate your method of payment(Required)

Self Pay

Health Insurance

Third Party Payer

Self Pay: If you have no available insurance coverage, you will be billed for services provided. Third Party Payer: We will attempt to collect from the third-party payer at the full cost of our services.

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Third Party Payer – provide a description(Required)

Describe anyone else the patient wants the office to bill.

Patient’s Printed Name(Required)

Financial Policy Acknowledgment(Required)

I have read and understand the Office Financial Policy above.

Patient Signature(Required)

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Patient Signature Date(Required)

Finance Counselor / Clinic Use

Finance Counselor

For completion by the finance counselor.

Finance Counselor Signature

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Finance Counselor Date

Office Financial Policy