Thank you for choosing ChiroFIT as part of your health care team. We are committed to providing the best possible care for you. In order to achieve this goal, we need your assistance in understanding our payment policy, which will be provided to you upon your initial visit. I understand that all fees for said services are due and payable on the date services are rendered. I agree to pay all such charges incurred in full upon presentation, unless other arrangements have been made in advance. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment. It is our office policy to collect 100% payment for any deductibles, co-pays, co-insurance and non-covered charges at EACH visit. Our office requires a minimum of 4 hours for any cancellation of appointments. Any MISSED/No Call No Show (NCNS) appointments will be charged a NON-Refundable fee of $50.00. I certify that the health insurance information that I provided to the Provider is accurate as of the date set forth below and that I am responsible for keeping it updated. I am responsible for any NON-Covered Therapies and I am responsible for payment upon each visit. ChiroFIT may bill insurance upon my request for any NON-Covered Therapy. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic. I authorize this office and its staff to examine and treat my condition as the Provider sees' fit.