Please read the following information carefully:
● All fees (including self-pay and/or co-pays, if applicable) are due at the time of service
● We accept cash, check, credit card, flex spending accounts, and Apple Pay as forms of payment
● Checks should be payable to: BridgeTower Chiropractic
● Upon request, we will provide you with an invoice outlining the services rendered at the amount charged
Please read and acknowledge the following:
I understand that I am responsible for all costs / fees that any third-party payer (ex. Insurance company) does not cover. In the event that a third-party payer source determines that rendered therapy services are “not covered” or otherwise denied, I will be responsible for all outstanding charges. I understand that I will be billed accordingly and will be responsible for immediate payment. I also understand that BridgeTower Chiropractic will not become involved in disputes between myself and my third-party source regarding
uncovered charges or reasons for denial.
I understand that if fees are not paid in full, treatment sessions pay be postponed or cancelled until payment is received.
I understand that all returned checks will be subject to a $20 returned check fee. Charges incurred and not paid after 180 days may be turned over to a collection agency at the client’s expense. Overdue accounts may also be reported to a Credit Bureau.
I understand that I am responsible for all legal and collection fees, which BridgeTower Chiropractic may incur if payment is not made in accordance with the terms and conditions herein.
I understand that refunds will be issued only in instances of overpayment. All refunds will be processed within 4 weeks after the overpayment is discovered on the client’s bill or at the time the refund is requested. Refunds for payments made with a credit card will be credited back to the credit card used, all other refunds will be issued by a check. Clients who used a third-party source will not be issued a refund until full payment is received from the appropriate source
I understand that all cancellations and reschedule requests require 24 hours notice and that there will be a fee assessed for any cancellations and reschedule requests made less than 24 hours. A larger fee will also be assessed for not attending my scheduled appointment with no prior This charge is my sole responsibility and will not be covered by a third-party source.