Drs. Martin & Stacy Steffensen, D.C

9795 95th St.

Boulder, CO80302

303-098-6070

Chiropractic Care Plan

______PM NAME______

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:

_36__ Chiropractic Office Visits Over

_12___Weeks

Spinal Postural Exercise Instruction

Neuro – Spinal Evaluations _3wks__

_7wks_, _12wks_, ______& ______

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

Name______Date______

Chiropractic Care Plan

Care Plan includes the following:

TOTAL VISITS: __36_____ (_12___ Weeks)

TOTAL INVESTMENT = $ _2280_____

All plans arediscountedfrom our customary fees to reduce out-of-pocket expense for patients

OPTION #1

Monthly Installment Plan (_10_ %) and SAVE $_228___ =$ _2052____

FIRST installment due today __750______2 monthly installments of _650____

OPTION #2

Reduced Monthly Option through Same As Cash Financing

(Outside Finance Company with NO Finance Charge)

ONE TIME DISCOUNT (_15_ %) and SAVE $_342____ =$__1938____

Pre-Approval Required to Determine Monthly Installment options

OPTION #3

ONE TIME DISCOUNT (_20___ %) and SAVE $_456___ =$ __1824____

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 forfeited.