Estimated Insurance Payment Form

Estimated Insurance Payment Form – Rockford, IL

PLEASE ADVISE THE FRONT DESK IF YOU ARE OR HAVE BEEN RECIEVING SERVICES AT ANOTHER FACILITY

File #

Date

Name

Last Name

Service Coverage

Chiropractic

QTY

Coverage %

Co-Pay

Primary Ins

Secondary Ins

Physical Therapy

QTY

Coverage %

Co-Pay

Primary Ins

Secondary Ins

Office Visit

QTY

Coverage %

Co-Pay

Primary Ins

Secondary Ins

Acupuncture

QTY

Coverage %

Co-Pay

Primary Ins

Secondary Ins

Health Insurance Benefits / Auto Injuries

Annual Deductible:

Co-ins / Co-Pay

Payment Agreement

By clicking, this box and entering my name is the signature field below, I (Patient/Guardian) agree to pay back full amount of deductible met by the provider whether the patient is under treatment or released from care.

Patient/Guardian Name (signature)

Biller Name (signature)

Insurance benefits are estimated based upon information from the insurance company. It is not a guarantee of payment. Patient/Guardian is responsible for the amount not paid by insurance.

EOB’s from your insurance company will state Integrative Family Healthcare as the service provider.

Please be aware that your insurance company will be sending you Explanation of Benefits (EOB) statements reflecting the deductible you have met with them. Please remember that you have made a financial arrangement with Circle of Wellness to help you meet your deductible over a period of time so that you may afford the treatment you need.

You will be responsible for the deductible that is met by Circle of Wellness, regardless of being an active or inactive patient.

Estimated Insurance Payment Form