Dear Patient:

 

INSURANCE COVERAGE, PAYMENTS & RELEASE OF INFORMATION

 

Elements in Harmony is OUT-OF-NETWORK only.

 

Many insurance policies cover acupuncture; however, we do not claim that yours does. Policies can differ greatly when it comes to deductible and percentage of coverage for acupuncture. If your insurance does not cover acupuncture or provide enough coverage to complete your treatment plan, we will provide you with the necessary documentation to pursue reimbursement.

 

I understand that I am receiving or about to receive health care services in this office. I understand that I am responsible to pay all non-insurance related fees when services are rendered, including but not limited to initial consultation, herbs, massage, additional services, etc. If I choose to use my insurance, I understand that I will be responsible for all “non covered” services and/or coinsurance/co-pays associated with my office visit. I also understand that I am responsible for the difference between what is billed to my insurance and what my insurance company pays and that this charge will be charged to my credit card on file once the explanation of benefits is finalized by my insurance company.

 

I understand that it is my responsibility to verify my benefits before starting treatment with Dr. Anna Dolopo and licensed acupuncturists at Elements in Harmony Acupuncture and Chinese Herbs. I accept responsibility for checking and confirming coverage for myself and others insured under my insurance plan. I also understand that any benefits verified by myself, or Wellness Billing Solutions, are not a guarantee of payment and that my insurance provider may deny coverages, even if earlier verification confirmed coverage. If any/all treatments are denied due to lack of coverage, I accept responsibility for full payment of all uncovered treatments.

 

In the case that treatments are denied due to lack of coverage, I hereby authorize Dr. Anna Dolopo to deduct the total payment amount from my authorized credit card on file.

 

I understand that my insurance company may require Dr. Dolopo and Elements in Harmony Acupuncture and Chinese Herbs to supply medical reports documenting my treatment and progress and authorize the release of all necessary medical information to process my claim.

 

Elements in Harmony (EIH) only bills for musculoskeletal pain (i.e., back pain) and nothing else. Fertility clients are 100% out of pocket. EIH charges $300 for initial consultation and treatment for non-fertility to your insurance, and $200 for follow-up acupuncture only for non-fertility treatment to your insurance. If you would like to receive a private consultation, there is an out-of-pocket fee of $50. If you cancel or change your appointment within 24 hours, there is an out-of-pocket fee of $100 that is non-refundable. If your insurance pays less than $300 for your initial treatment, your credit card on file will be charged the difference. We collect $300 for the initial treatment for insurance-based patients. If your insurance pays less than $200 for your follow-up treatment, your credit card on file will be charged the difference. Our insurance rates are customary and reasonable to insurance companies. Our non-fertility out-of-pocket rates are lower than the insurance rate.

 

EIH will bill up to 10 acupuncture treatments. If payment is not received in full by then, we will pause insurance-covered treatments until your insurance starts to pay. You are welcome to pay out-of-pocket without refund for those paid out of pocket at our cash-based fees.

 

EIH only charges for musculoskeletal acupuncture and no other services. Massage, fire cupping, moxibustion, cosmetic acupuncture, fertility acupuncture, etc., are paid out of pocket.

 

Thank you for your consideration,

 

 

Dr. Anna Dolopo & Elements in Harmony Acupuncture & Chinese Herbs Licensed Acupuncturists