As a self pay patient electing not to use medical insurance at
Active Body Chiropractic, I will receive a 25% discount for services
rendered that are paid on the same day. If no prior arrangements
have been made with the office manager and I am unable to pay
on the date of service, I will not receive the discount. (*Note:
this percentage discount is rounded to nearest dollar increment
for simplicity of billing. See fee examples below.)
As a “self pay” patient, I understand
that Active Body Chiropractic (ABC) will not be responsible for
dealing with any third party payers (insurance companies) on my
behalf. If I am using the time of service discount, ABC will not
accept payment directly from my insurance company. I accept any
and all responsibilities and liabilities in dealing with third
party payers in regards to attaining reimbursement for services
rendered at ABC. I hold harmless ABC from any complications that
may arise in my attempts to receive compensation from any third
party payer.
ABC can provide a ‘superbill’ with diagnosis
and procedure codes directly to me for my own claim submission.
Alternatively, ABC can send a claim form to my insurance company
on my behalf for a one time setup fee of $10. This is the extent
of the aid ABC can be expected to give in helping me bill my insurance
company if I elect to receive the time of service discount.
If ABC is required to spend any time or effort in
the future, in any manner, to assist me in the reimbursement process
other than submitting a claim or providing a superbill, I understand
that an additional compensation must be paid by me to ABC. I will
compensate for the additional times spent at the rate of $25 per
hour and $1 per page for medical record printing.
TYPICAL FEES WITH TOS DISCOUNT:
A new patient first appointment is $145 (exam + two units
of soft tissue...normal price $195)
A follow-up visit for therapy is $80 (chiropractic + two
units of soft tissue...normal price $110)
A chiropractic manipulation with no soft tissue work is $30
(normal price $40)
FEE BREAKDOWN BY INDIVIDUAL CPT CODES:
|
CPT
|
Description
|
Standard Insurance Price
|
TOS Discount Price
|
|
98941
|
Chiropractic Care 3-4 areas
|
40
|
30
|
|
97110, 97112, 97140
|
Active Release Technique, Graston, other
soft tissue techniques, 8-15 minutes
|
35
|
25
|
|
99203
|
New Patient Examination
|
125
|
95
|
