We are dedicated to providing you with high quality healthcare. By signing this form, you acknowledge and intend to adhere to the financial policies set by our practice.

Retaining Credit Cards on File Our office requires retention of an active credit or debit card on file via Credit Card Authorization form. We may use this card on file to bill any balances indicated as patient responsibility by your insurance or to reconcile any balances beyond 30 days. Health Savings and Flexible Spending cards are acceptable forms of payment; however, we will require an additional card on file in case the available funds on those cards have been exhausted. All credit card information is encrypted and stored securely and is not shared with any third party. If you elect not to keep a credit card on file with our office, you must pay for your services in full, prior to the services being rendered, regardless of if you are using private insurance to process your claim. There are no exceptions. Any patient credits that are a result of a claims processing will be applied to your account to use towards future balances (copays, coinsurance, services and/or products) or can be refunded to you upon request.

Initial Evaluations and Re-evaluations For acupuncture, we administer a 30-minute initial evaluation for all patients. This service is usually performed via telehealth communication in our Frederick location, and in-office in our Boonsboro location. The self-pay fee for this service is $85.00. If you are using your insurance to process your claims, we will bill the service to your insurance company. If your insurance denies the charge, you will be financially responsible for the service in full. Your policy may also have additional copay for evaluation services. About once per month, your provider will also bill your insurance for a re-evaluation in addition to your acupuncture. This re-evaluation charge is the provider billing for the extra time spent evaluating your case. It may not necessarily mean that anything will be different with the acupuncture portion of your treatment. Our providers usually spend time on your case before and after the appointment which could mean thoroughly documenting their treatment notes, researching and evaluating your case, and/or discussing methods with other providers. The extra charge aside from acupuncture is for that time spent. Re-evaluations are a standard our office has set and occur across all patients and cases. If your insurance company denies any of the charges, you will be financially responsible for the services in full.

Self-Pay Payment is due in full at the time of your appointment unless you have elected to pre-pay for services. We accept cash, check and credit card payments. There will be a $30 fee assessed to your account for a returned check.

Private Insurance Our office(s) can bill your insurance company for acupuncture services. We do not bill insurance for massage but can provide you with a Superbill to submit for reimbursement. Beyond the practice of medicine, all healthcare providers are faced with the task of working with many different insurance companies who help coordinate your care and meet your medical financial responsibilities. By signing this form, you acknowledge your financial responsibility, including your responsibility to be aware of what your insurance does and does not pay for, as well as any patient responsibility amounts. Your insurance policy is a contract between you/your employer and the insurance company – our office is not party to that contract. Please read your Evidence of Coverage booklet that you received from your insurance company as to what types of services are not covered under your policy or contact your insurance company directly if you have specific questions about your coverage. After each appointment, we will bill your claim to your insurance for you and your insurance company will return an Explanation of Benefits (EOB) to us within 2-6 weeks. The EOB will contain details of how they processed your claim; dictating patient responsibility amounts and also any payment amount to our office. We currently accept and process for participating Aetna, Blue Cross Blue Shield, and United Healthcare plans that cover acupuncture. We will also process to insurance when Medicare is primary and one of the aforenamed insurance providers is secondary with acupuncture coverage. If you change insurance companies or employers, or your policy is updated or changed, you agree to provide our office with the current information immediately.

Copays and Co-Insurance All copays and coinsurance are due at the time of service. Your policy may have additional copay for evaluation services.

Deductible Your deductible is the amount your insurance company requires you to pay out of pocket before your insurance company will pay for your claims. If your policy is determined to have a deductible that applies to acupuncture, you will be charged the estimated deductible costs at the time of the appointment. Any differences determined after our receipt of the EOB from your insurance company, will be reflected on your account. Any additional balances owed will be due at your next appointment or during end of the month reconciliation – whichever comes first. Any balances beyond 30 days will be charged to your credit card on file. Any credits will be reflected on your account to use towards future purchases (copays, coinsurance, services and/or products).

Denials If your insurance company denies services, we will do our best to appeal the claims on your behalf – we want to help! However, this is not a guarantee the denial will be overturned, and the claims will be paid. Although it is rare, sometimes your final insurance coverage determined during claims processing can differ from the information relayed originally. Not all diagnoses codes may be covered under your plan. Please be aware that some and perhaps all of the services provided may be considered non-covered or denied under your plan based on the limitations in your policy. Any non-covered or denied services will become your full financial responsibility. Any unpaid balances on your account after 30 days, will be charged to your credit card on file.

Opting Out of Insurance If benefits are determined through your policy but you do not wish to process through your insurance, you have the option to sign an insurance waiver provided by our office and pay the self-pay rate for services instead.

Worker’s Compensation and Motor Vehicle Accidents/Personal Injury We do not process to Worker’s Comp, Auto Accident or Personal Injury claims. In a case where a third party may be liable for payment of your bills, you are responsible for your charges and we require payment in full at the time of service. We can provide you with a Superbill receipt to submit for reimbursement upon request. We will not sign a Doctor’s Lien with your attorney. We are not legally permitted to bill your private insurance for these services unless subrogation has been identified in writing between your private insurance and your worker’s comp/personal injury insurance companies.

Office Records A $25 fee will be assessed for a compilation of your medical records.

Herb Return Policy Herbs returned within 2 months (60 days) from the date of purchase and unopened are eligible for a full refund.

Cancellation Fee An appointment reserves time with a practitioner. To ensure that the maximum number of patients can receive care when needed, we require notification of any appointment changes 24 hours in advance of your appointment. A $65 fee will be assessed for any missed appointments or cancellations with less than 24-hour notice. Any cancelled/missed appointments are best to reschedule within the week to maximize your benefit of care and follow the treatment plan your practitioner has outlined for you. In the event of severe weather or medical emergency, exceptions to this policy are made. Electronic Appointment Reminders via text and email are sent as a courtesy and inability to receive one is not an excuse to miss an appointment. Ultimately, it is the responsibility of the patient to keep track of their appointments. Disputing cancellation fees or non-adherence to office policies could result in scheduling privileges being revoked.

By signing this form, I have read, understand and agree to the Financial Policy of Holistic Health Associates described in this document. I have had an opportunity to ask questions and am fully aware of what I am signing. I intend this form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment or until a new form is signed and retained on file by this practice.