The Intention Wellness Center Financial Agreement

The purpose of this Agreement is to clarify your financial responsibilities so we can devote our efforts to helping you get the best results in the shortest amount of time. The following are the most common services we provide and when they are performed.

Procedure	Purpose	When Performed	Fee
Consultation	Tour the office, meet the staff, discuss your health with the doctor.	First visit	N/C
Evaluation	Determine the nature and severity of your health problem, assess your current status and determine an appropriate course of action.	First visit, new conditions & exacerbations	$97.00
Healing Session	Reduce the effects of stress on the body and clear out imbalances within the nerve system (discounts available for students and seniors).	As indicated by evaluation	$57.00
The Club	Provides a 20% discount on all above services. Encourages you to stay well after you get well, by using our services on a monthly basis.	Annual membership	$57.00

Forms of Payment

Patients are responsible for full payment at the time of service. We accept cash, personal checks, Visa, MasterCard, American Express and Discover. Any other arrangements must be authorized in advance.

Insurance Co. / 3rd Party

All professional services are rendered and charged to the person receiving care and not to an insurance provider. We will supply you with statements, reports or other documents to help you receive reimbursement from a third party.

We will not become involved in disputes with your insurance company regarding deductibles, co-payments, covered charges, secondary insurance, “usual and customary” charges, etc., other than to supply factual information.

Billing

Any outstanding balances are billed monthly and considered past due 10 days after the invoice date. Returned checks are subject to a $25.00 fee. Balances older than 30 days will accrue interest charges of 1.5% per month, plus any legal or collection fees.