Drs. Eddie & Cathy Levine, D.C
9795 95th St.
Chiropractic Care Plan
Network Chiropractic Spinal care is an excellent investment in the overall health and well-being of children and adults. Financial considerations should not be an obstacle to obtaining this important health service. We are sensitive to the fact that each household has unique circumstances regarding the fulfillment of their financial obligations. Therefore, our office has created a number of cost-effective payment plans to make the care you need affordable.
The goal of this plan is Improved Spinal and Neural Integrity, Re-education and Enhanced Wellness. Based on the doctor’s recommendations, the following plan has beencreated for you.
Primary Services Provided:
_____ Chiropractic Office Visits Over
Spinal Postural Exercise Instruction
Neuro – Spinal Evaluations ______
______, ______, ______& ______
Full Re-X-Ray (if necessary)
Additional Services Include:
New Patient Spinal Orientation Dinner (includes up to 4 guests)
Attendance to our Wellness Workshops
Complimentary Family Evaluations within the first 14 days
Consultations with the Doctor as Needed
Chiropractic Care Plan
Care Plan includes the following:
TOTAL VISITS UP TO: ___90___(_50_ Weeks)
TOTAL INVESTMENT = $ _5600____
All plans arediscountedfrom our customary fees to reduce out-of-pocket expense for patients
Monthly Installment Plan (_15_ %) and SAVE $_836____ =$ __4764___
FIRST installment due today ____490____ 11 monthly installments of __388____
Reduced Monthly Option through Same As Cash Financing
(Outside Finance Company with NO Finance Charge)
ONE TIME DISCOUNT (_20_ %) and SAVE $_1120___ =$___4480____
Pre-Approval Required to Determine Monthly Installment options
ONE TIME DISCOUNT (_25_ %) and SAVE $_1330__ =$ ___4270____
I choose option # ______
Patient Name: ______
Patient Signature: ______Date: ______
Witness: ______Date: ______
*All monthly payments must be ‘auto debited’ through electronic checking, debit card, or credit card withdrawal to qualify for discounted fees. Advance payment reduces our bookkeeping expenses therefore we pass the savings on to you. Fees apply if payment is not automatic. A $20.00 per month surcharge applies if patient does not authorize automatic payment.
- Care may be stopped at any time; however, fees will be re-calculated at our normal ‘itemized pay per visit’ fees if care is stopped prematurely before the end of the plan. Any refund owed or outstanding payment due is based on “itemized pay per visit” fees (i.e. discounts are lost). You are responsible for full payment for all services rendered.
- As a customer courtesy we will provide you with a ‘claim ready’ receipt(s) to submit to your insurance company. It is your responsibility to submit your claims and to dispute any non-payment with your insurance company.
- Use Visits Within Care Time Frame - Members must use all regular network office visits within the agreed upon billing period. If all visits are not used within the agreed upon time frame the visits will be forfeit.