Acupuncture Physiciansof Colorado Rosalie A. Bondi, D.O., M.A.O.M. 9101 Harlan Street Suite 350 Westminster, Colorado 80031 720-381-6100 Fax: 720-381-6133

PaymentPolicyforAcupuncture,CuppingandOsteopathicManipulativeTherapies

(NotapplicableforWorkers’CompensationPatients)DuetothegrowingproblemswithInsurancecompanies,weareaskingourpatientstotakeamoreactiveroleinknowingtheirhealthcarebenefits.Makesureweareinnetworkwithyourplan.Pleasemakesureyouknowyourcopay,coinsurancerate,anddeductibles,aswellasanyotherspecialrequirementsbyyourinsurancecompany.Unfortunately,wecannotverifyAcupuncture,CuppingandOsteopathicManipulativeTherapiesbenefits,becausebenefitswillonlybeknownforsurewhenclaimsareactuallyprocessedthroughyourInsurancecarrier.Westronglyencourageallourpatientstoknowtheirinsurancepolicies/benefits.Infollowingtheabove,therewillbelessconfusionlaterandabetterunderstandingofwhatservicesarecovered,andwhatyouwillbeexpectedtopay.IfAcupuncture,CuppingandOsteopathicManipulativeTherapiesaredeniedinsurancebenefits,theseserviceswillbebilledatproviderdiscountedratesstatedbelow:ProviderDiscountedrateforAcupuncture$40.00pervisit.ProviderDiscountedrateforCuppingTherapy$15.00pervisit.ProviderDiscountedrateforOsteopathicManipulativeTherapy$50.00pervisitInaddition,youwillberesponsiblefortheofficevisitcopayaswellasanycoinsuranceanddeductibles.Bysigningbelowyouareagreeingtothesetermsandagreetopaytheaboveproviderdiscountedratesifyourinsurancecarrierdeniestheaboveservices._______________________________________________________________________________________PrintNameSignatureDateAcupunctureandOsteopathicManipulativeTherapyareconsideredaspecialtypractice.Ifyouneedareferraltoseeaspecialist,pleasecontactyourprimarycarephysician.Youareresponsibletoobtainareferralfromyourprimaryphysicianpriortoyourscheduledappointment.Bysigningbelowyouareagreeingtothetermsandagreetopayself-payrates(statedbelow)ifyoudonotobtainareferralfromyourprimarycarephysician._______________________________________________________________________________________PrintNameSignatureDateInsurancecompanieshaveastrictandtimelyfilingprocess.IunderstandthatitismyresponsibilitytoimmediatelynotifyAcupuncturePhysiciansofColoradoofanychangesinmyInsurancecoverageorIwillberesponsibleformybill._______________________________________________________________________________________PrintNameSignatureDate

Self-PayRates(ifapplicable)

TimeofService/Self-payratesare$175.00fortheinitialvisitand$120.00foreachfollow-upvisit.TheseratesincludeanofficevisitaswellasAcupunctureand/orCuppingTherapyand/orOsteopathicManipulativeTherapy._______________________________________________________________________________________PrintNameSignatureDateIfwehavebilledyourclaims,ourBillingDepartment@720-291-5201willassistyouwithanyproblems,concernsorquestions.