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Office Policies

Our office is a zero balance office. All services including co-payments must be paid for at the time of service unless other arrangements have been made. All missed appointments must be made up according to your care plan. Please call 24 hours in advance if you need to reschedule your appointment.

Assignment of Benefit/HIPAA Guidelines

I certify that, I, and/or dependent(s) have insurance coverage with _________________________ and assigned directly to Advanced Wellness Center all insurance benefits, if any, otherwise payable to me for services rendered. I authorize the use of my signature on all insurance submissions. The above-named facility may use my health care information and may disclose such information to the above-named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. I am aware that Advanced Wellness Center (AWC) will abide by the HIPAA regulations for the purpose of keeping my records confidential and only upon my written consent will my records be allowed to leave AWC.

Signature of patient, parent or guardian Date

Print name of patient, parent or guardian Date

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