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 doctors see fit. 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 understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between the insurance carrier/s and myself. This clinic can accept direct payment from insurance companies. This service is provided to our patients at no additional charge. It is possible that your insurance company may or may not pay for all treatment or services you receive on any given visit. We always work with you to find the most cost effective plan. Additionally, our clinic will prepare any necessary reports and forms to assist you in making collection from the insurance company or flexible spending accounts. I clearly understand and agree that I am personally responsible for all fees incurred in providing my care. Payment for services is expected in full at the time of service, unless other approved arrangements have been made. If you suspend or terminate treatment, any outstanding fees for professional services will be immediately due and payable. We will work with you as much as possible, if you are actively attempting to clear up your balance. Balances over 60 days late will incur a 5% late charge and delinquent balances over 90 days are subject to being sent to a collection agency, although we do everything possible to avoid this action. You will then be responsible for any and all costs incurred in the collection of your debt, including charges levied by the collection agency (currently 28%). You will also be responsible for any attorney fees, court fees, and any other fees incurred by Bolingbrook Family Chiropractic in the collection of your debt. Lastly, your account may be subject to a $25 charge in the event that you do not provide ample notice before missing your scheduled appointment (90 minutes minimum). Please let us know if you can not make it so we may open that time up for someone else.