Estimated Financial Worksheet 2

Terms:

This arrangement is for a block of treatment visits. The conclusion of this block of visits does not mean that your care is completed, or that you have returned to an optimum state of wellness. You may need either more or less treatment than is indicated in this arrangement, according to your individual case. The length of treatment of this block is based on your examination findings. There may be factors that we have no control over such as re-injury the physical demands of your employment, complicating factors, and most importantly, your compliance with the doctor's instructions and treatment plan. This is a financial agreement and not a guarantee of wellness. Wellness credits are nontransferable and may only be redeemed upon the completion of estimated visit recommendations. If you discontinue care for any reason other than discharge by the doctor, all balances will become immediately due and payable in full by you, regardless of any claim submitted.

If you prematurely discontinued treatment, a pro-rated reund will be made if there is a credit balance after the deductible and co-payments have been satisfied, and only after all claims have been paid by your insurance company. If you go more that 90 days without treatment, you will be considered inactive and will forfeit any wellness credits that you had. If you wish to return for evaluation or treatment after 90 days, there will be a $60-reactivation fee.

Refunds: Refunds will be provided and paid within 90 days of the receipt of the written termination request from the patient or from the date in which this office terminates this agreement. The refund amount will be based upon this agreement fee less the total number of individual services performed calculated at this office's normal fee schedule for these services. If the services performed are equal to or greater than the agreement fee, then there will be no refund or monies owed either to our office or to the patient.

For Office Use Only: (Print Page prior to filling out)

For your convenience, you may retain your credit card number on file with us. Patient authorizes payments to be charged per above schedule.