I hereby acknowledge that I am receiving (or am about to receive) treatment at Germantown Chiropractic, PSC and that I have been advised that the doctor providing the services is (are) willing to wait for payment for these services, provided that there continues to be reasonable certainty that payment will be made either by insurance proceeds or out of the settlement of liability.
I understand that if it is determined either:
- That there is no insurance company obligated to pay for these services, or if the insurance company involved refuses to acknowledge an assignment to the doctor or make other provisions for the protection of the interest of the doctor or
- If a liability claim exists, and my attorney refuses to agree to protect the interest of the doctor, or I have not engaged in the services of an attorney, then payment for services rendered by the doctor at Germantown Chiropractic PSC, will be made by me on a current basis and my bill will be paid in full as soon as my liability claim is settled or the passage of three months from my last treatment, whichever comes first.