I agree that I am financially responsible for and will pay all incurred charges for all services provided by the Practice and its employees, contractors and providers. The Practice maintains a standard fee schedule, subject to change from time to time. All services shall be paid pursuant to the Practice's then current fee schedule in accordance with the Practice's then-current payment policies, which currently require payment within 30 days of an invoice statement date. I agree to present current insurance information at each visit to the Practice. I understand and agree that if I have health and/or accident insurance policies, that these policies are an arrangement between my insurance company and/or government program and myself. I understand that my insurance benefits may cover part, or none of the services rendered by the Practice. It is my responsibility to understand my insurance benefits including, without limitation, my copays, coverage and deductibles, and any required referrals should I seek to obtain reimbursement from third party payors myself. Any deductibles or copays owed to the Practice pursuant to my insurance policy will not be waived. I understand that it is my responsibility to notify the Practice of any and all changes to my insurance company, plan and/or benefits. I understand that if no insurance coverage exists for any services or products that I receive from the Practice or my insurance carrier(s) fails to pay the Practice, I am financially responsible for the incurred charges and I agree that the above paragraph does not release me from such responsibility. I clearly understand that I am financially responsible for all charges whether or not paid by my insurance carrier or third-party payor. I further agree that I will pay all such incurred charges in accordance with the Practice's then-current payment policies and procedures. I understand that the Practice has the right to forward unpaid accounts to a collections agency and I agree to bear and reimburse the Practice for all costs associated with the Practice's collection efforts on my account.

Late cancellations of less than 2 hours, and patients who do not show for a scheduled appointment will be charged $25.00.

If the services provided are payable under a Medicare or other applicable government or commercially provided benefit, I hereby authorize my payor and/or insurance company to pay the Practice directly for any care I receive from the Practice. I hereby assign all payments and medical benefits directly to the Practice for services rendered by the Practice that would otherwise be payable to me. I understand that any such assignment of benefits imposes no obligation for the Practice to collect money on my behalf.

I hereby agree that the services that I receive from the Practice will consist of the provision of pain and wellness treatments and related items and services.

This serves as notice that as part of our efforts to deliver the most consistent healthcare we can to every patient, we use an electronic healthcare system that enables us to retrieve up to 13 months of prescription history through your insurance carrier.