Financial Agreement

​
 

• Payment of all visit fees is expected at the time of service.

• We will assist you in submitting claims to your insurance carrier, however, it is your responsibility to check insurance benefits and coverage. You will be responsible for any non-covered services, deductibles, co-payments, or co-insurances, as determined by your insurance carrier. 

• You authorize payment of medical benefits directly to Legion Health for all services rendered where applicable.

• You authorize Legion Health to release to government agencies, insurance carriers, and all others who are financially liable for your care, all information to substantiate payments for your care and to permit representatives thereof to examine and make copies of all records related to such care and treatment. You understand that if at any point your insurance coverage changes, you are to notify administrative staff prior to your next visit. Failure to do so will result in being personally and completely responsible for the full amount of all services.

• You will be responsible for a late cancellation/no-show fee of $100 for intake visits and $50 for followup visits if the visit is not rescheduled/cancelled at least 48 hours in advance.

• You will be subject to finance and/or legal fees in addition to the total account balance if you default on payment.