Financial Policy

Thank you for choosing PCG as your health care provider. We are committed to the success of your treatment. The following are statements of our Policies which we require you read and sign prior to any treatment. All patients must complete our Patient Information, Health Information, Policy and Coverage forms before seeing the chiropractic physician.

FULL PAYMENT IS DUE AT TIME OF SERVICE UNLESS CARE IS PURCHASED UNDER A QUALIFIED PRE-PAYMENT DISCOUNT PROGRAM. WE ACCEPT CASH, CHECKS, CREDIT AND DEBIT CARDS. WE OFFER AN EXTENDED PAYMENT PLAN WHERE NECESSARY AND WHERE THIS FINANCIAL AGREEMENT IS SIGNED.

Your care constitutes services that are appropriate for your condition, but which are not covered under any health benefit plan and include services that may be considered experimental/investigational, injury prevention, palliative, wellness, maintenance, supportive care and/or general exercise. You have the right to deny receipt of these services. If you elect to receive recommended non-covered services, you will be fully responsible for payment of those services and agree that these services will not be reported to any insurance carrier. Even where PCG is a participating provider with an insurance plan, it is not obligated to report non-covered services on your behalf. This includes Medicare/Medicaid and other federal healthcare programs. To the extent that you have insurance benefits, you have the ultimate responsibility for knowing and understanding the coverage limitations of your insurance benefit contract. You are responsible to verify your coverage limitations based on your benefit contract.  Fees charged for non-covered services will be determined by agreement between PCG and the patient. Non-covered services may qualify for reimbursement under a Health Savings Account as a medical expense. Where necessary, a receipt can be supplied for documentation of these services. You are responsible for submission of any claim for reimbursement from your Health Savings Account.

If financial hardship is demonstrated, we can allow a sliding scale discount based upon your gross household income and number of family members as compared to federal poverty guidelines to accommodate financial limitations in order to provide quality care. Services provided will be considered non-covered and therefore not reimbursable or reported to your insurance carrier.

Adult patients are responsible for full payment at time of service unless we are accepting assignment of your insurance benefits for covered services under a compensable auto or workers compensation claim. We will attempt to identify what these amounts are likely to be where possible.  

The adult accompanying a minor and the parents (or guardians of the minor) are responsible for full payment unless we are accepting assignment of your insurance benefits for covered services under a compensable auto or workers compensation claim. For unaccompanied minors, non-emergency treatment will be denied unless payment has been pre-authorized by the parent or guardian of the minor patient to an approved credit plan, Visa/MasterCard, or payment by cash or check at time of service has been verified in advance of treatment.

Permission is hereby given by the undersigned to the physicians of PCG and whomever they designate to treat the minor patient and to bill for the services provided according to the credit instructions provided. I certify by my signature below that I am the minor patient’s parent or legal guardian who is legally authorized to make treatment decisions on the minor patient’s behalf.

Please help us serve you better by keeping scheduled appointments. A fee of $25.00 or the anticipated appointment fee, whichever is less, may be charged for missed appointments or canceled appointments where the appointment is cancelled with less than 24 hours advance notice.