Restore Balance To Your Life & Body
*Please note that these policies apply to Acupuncture & Wellness Center patients only.
Acupuncture & Wellness Center strives to provide the most professional care for our patients. In doing so we provide a structure in our treatment schedules that enable us to ensure the best care for all we serve. Therefore we ask that you provide us with at least 24 hour notice if for some reason you have to cancel your appointment. No shows or frequent last minute cancellations will mean that a slot that could have gone to another patient would be unfilled. Therefore under these circumstances we will have to charge $40 missed appointment fee. We thank you for your understanding.
We do not bill insurance companies for missed appointments or late cancellations (less than 24 hours notice). You are responsible for paying the missed appointment/late cancellation fees.
Once your insurance is verified, we will bill and accept payment from your insurance company for covered services. In the event that the insurance company denies payment or makes a partial payment, you are responsible for the balance, deductibles, and co-pays. Your signature below confirms your financial responsibility for all services regardless of insurance reimbursement.
ASSIGNMENT OF BENEFITS:
Your signature authorizes and directs payment of medical benefits to the acupuncture practitioner for services provided by this office.
RELEASE OF MEDICAL RECORDS:
Your signature authorizes the release of all of your medical records on file in this office, for the purpose of processing your claims to the following: your attorney, the health care providers attending to this condition, and the insurance case managers. Medical records will not be edited unless otherwise stated in an exclusive release of medical records signed through your attorney.
Appointment times are as scheduled and cannot extend beyond the stated time to accommodate late arrivals. Please arrive 5 minutes prior to your scheduled visit so that your treatment can begin on time. We understand that occasionally delays will lead to arriving late to an appointment. However, as we make every effort to see you on time, we must ask that you call our office if you anticipate being late for an appointment. For patients showing up later than 10 minutes, we may have to reschedule your visit so that we can be punctual to our next appointment. You will still be responsible for the full payment.
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+1.443.219.1220 • 8813 Waltham Woods Road Suite 102 Parkville MD 21234 US