When a person seeks chiropractic health care and we accept someone for such care, it is essential for both the chiropractor and the patient to be working towards the same objective. Chiropractic has only one goal, to detect and reduce/correct subluxation. It is important that each person understands both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment. ADJUSTMENT: An adjustment is the specific application of forces to facilitate the body’s correction of subluxation. Our chiropractic method is by specific adjustments of the spine and/or extremities. HEALTH: A state of optimal physical, mental, and social well-being, not merely the absence of disease or infirmity. SUBLUXATION: A misalignment of a joint which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body’s innate ability to express its maximum health potential. We do not offer to diagnose or treat any disease or condition other than subluxation. However, if during the course of a chiropractic evaluation, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider specializing in that area. Regardless of what disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by other health care professionals. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body’s innate healing ability. Our only method is through specific adjusting to correct subluxations. If a lifetime of a better functioning body is what you want for you, your family, and your friends, then welcome . . .you are in the right place.

Select Chiropractic will try to assist patients in obtaining insurance benefits whenever possible. It must be understood, however, that: The patient is responsible for full payment of all services rendered on their behalf or on behalf of their dependent. We will call to verify benefits. However, we cannot be responsible for errors in the quoting of benefits. We suggest that you become aware of your own benefits, deductibles, and maximums, etc. Insurance is a contract between you, the Insurance Company, and/or your employer. Select Chiropractic is not a party to that contract. Assisting you in trying to obtain payment is a courtesy and may be withdrawn at any time. Other insurance carriers are billed weekly by Select Chiropractic. Insurance payments are generally received within 30 days. The maximum time limit that Select Chiropractic extends is 60 days. Thereafter the patient must pay the fees in full. If we are requested to fill out additional forms, a clerical fee of $5.00 per form is due in advance. Patients must stay current with the full amount of their percentage of responsibility (e.g. if the insurance is expected to pay 80% of the bill, the patient must pay at least 20% of the charges). This must be paid at least weekly. If the patient discontinues care for any reason other than discharge by the doctor, the patient must pay the outstanding balance in full, immediately—regardless of any claims submitted. If the patient fails to keep regular appointments, they will be discharged. The patient must pay the outstanding balance in full, immediately All deductible amounts must be paid prior to submission for insurance benefits. If there is any balance due after the Statement of Benefits is received from the insurance carrier, that balance is due from the patient immediately. If the patient fails to pay off the balance due or make payments, the account will be turned over for collections after 45 days of non-payment. The patient will also be responsible for any collection fees acquired in the collection process. Any refunds made to patients will be based on the full account balance, without presuming further insurance benefits that may be payable. I have read, understand, and agree to the above. Furthermore, I hereby authorize and request that insurance companies pay directly to Select Chiropractic any insurance benefits for chiropractic care, health-related service, and durable medical equipment that would otherwise be payable to me. Indicate name.