Natural Medicine Works

Financial Responsibility Form

Dr. Coleen Murphy ND, LAc. and the practitioners of Natural Medicine Works do not participate in any insurance plans for naturopathic medicine as "in network providers".

I understand and agree that payment in full is required at each visit. I agree that I am responsible for payments for services my insurance carrier may determine non-covered, excluded, unreasonable or not medically necessary.

There is no credit extended for services rendered unless an alternate plan is agreed to before appointment time. I am responsible for charges incurred for all appointments, whether by phone, video chat or face to face.

I understand my responsibility to pay includes fees for laboratory or other clinical services requested by Dr. Murphy. I also agree to be responsible for costs and expenses, including court costs, attorney fees and interest, should it be necessary for Natural Medicine Works to act to secure payment of an outstanding balance owed.

To hold an appointment, a check or credit card deposit equal to the amount of service is required at time of booking.

If I write a check that is returned for non-sufficient funds, or any other reason, I agree to pay a $25 fee. At your appointment you may pay with cash, check or Visa/Mastercard.

Cancellation policy is as follows:

If appointments are canceled with less than 24 hours notice, no refund will be given.

If appointments are canceled between 48 and 24 hours notice, half payment will be reimbursed.

If appointment is cancelled with over 48 hours notice, all moneys will be refunded.

I also understand that, if my health insurance plan or health savings account (HSA) provides reimbursement for services rendered by non-participating providers, I may submit a claim myself to request reimbursement. I understand that it is my responsibility to know my plan benefits and that Natural Medicine Works is not responsible for determining these benefits. If requested, Natural Medicine Works will furnish me with a receipt to assist me to obtain reimbursement from my health insurance plan or HSA.

By checking this box _________ I am signing electronically.

Patient Signature	Date

Name Credit Card Number and EXP Date