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Insurance Policy Information
We understand how confusing insurance coverage can be. Please
understand that we do not guarantee any benefits from your
insurance company. Unfortunately, insurance companies often
misquote benefits to health care providers. Therefore, we recommend
that you contact your insurance providers personally to confirm your
individual chiropractic and/or acupuncture benefits. While we know
how frustrating it can be, La Costa Chiropractic and Wellness is not
liable for any misinformation given. We accept assignment as a
courtesy to our patients, but require our patients to be responsible for
their own benefits.
It is understood and agreed that I shall pay the full amount of the
charges should my condition be such that it is not covered by my
insurance policy or if for any reason the insurance company fails to pay
my claim.
Please sign your name below, indicating that you have read,
understand and agree to all of the above.
_______________________________________ Patient Name (Please Print)
_______________________________________ Patient Signature or Legal Guardian
_______________________________________ Date Signed