Financial Policy

Thank you for choosing us as your Pain Management Specialists. We are committed to your treatment being successful. The following is a statement of our Financial Policy, which we require you to read and sign prior to any treatment in our office.

All patients (parents or guardians) must complete our Patient Informantion and Fiancial Policy before seeing the Provider.

– PAYMENT IS DUE AT TIME OF SERVICE
– WE ACCEPT CASH, CHECKS AND VISA/MASTERCARD
– WE OFFER A PAYMENT PLAN WITH PRIOR BUSINESS OFFICE APPROVAL
– 10.5% APR ASSESSES ON ALL ACCOUNTS OVER 60 DAYS
– THERE WILL BE A $25.00 SERVICE CHARGE ON ALL NSF CHECKS.

Regarding Insurance:
It is our goal to provide fast and efficient billing as a courtesy to you. We need your help to accomplish this goal by proving complete and accuarte insurance information. Knowledege of your deductible and co-pays is your responsibility. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. If for any reason your insurance coverage changes, it is your responsibility to inform Integrative Pain Center of Alaska, LLC in a timely manner. If you fail to inform us within 60 days of the change, the Integrative Pain Center of Alaska, LLC will not be responsible for filing your insurance. Please be aware that some, and perhaps all of the service provided may be non-covered services. Some insurance companies reduce or deny benefits saying they are not considered USR (usual, customary or responsible). Please be advised that our fees are based on a national geographic standart and are, in fact, UCR for Alaska.

All deductibles and co-pays are due and payable at the time of treatment. The balance is your responsibility whether your insurance company pays or not. In the event that your insurance coverage changes to a plan where we are not participating providers, refer to above paragraph.

Usal and Customary Rates
Our Practice is committed to providing the best treatment for our patients, and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s determination of usual and customary rates.

Minor Patients
The adult accompanying the minor, the parents (or legal guardians) of the minor, are responsible for payment.

Thank you for understanding our Financial Policy. Please let us know if you have any questions or concerns.
I have read, understand and agree to this Financial Policy:

Patient’s Name:
Relationship to Patient:
Signature of Parent or Responsible Party:
Date: