Insurance Policy Information

We understand how confusing insurance coverage can be. Please

understand that we do not guarantee any benefits from your

insurance company. Unfortunately, insurance companies often

misquote benefits to health care providers. Therefore, we recommend

that you contact your insurance providers personally to confirm your

individual chiropractic and/or acupuncture benefits. While we know

how frustrating it can be, La Costa Chiropractic and Wellness is not

liable for any misinformation given. We accept assignment as a

courtesy to our patients, but require our patients to be responsible for

their own benefits.

It is understood and agreed that I shall pay the full amount of the

charges should my condition be such that it is not covered by my

insurance policy or if for any reason the insurance company fails to pay

my claim.

Please sign your name below, indicating that you have read,

understand and agree to all of the above.

_______________________________________ Patient Name (Please Print)

_______________________________________ Patient Signature or Legal Guardian

_______________________________________ Date Signed