Terms of Membership Agreement and Acceptance of Care
Responsibility for Cost of Care – Patient acknowledges that they are solely responsible for the entire cost of the care plan. Upon request, we will provide receipts reflecting cash fees paid containing adequate information for an insurance company to process claims for personal reimbursement. No claims are made guaranteeing reimbursement or payment from any insurance carrier. Be aware that most insurance plans impose significant restrictions on number of visits allowed and impose dollar limits on amount of reimbursement.
Additional Visits, After Hours and Non-Included Services – Additional visits beyond services listed will be charged at our regular fees. Nutritional supplements, chiropractic pillows, other products, emergency or after hours visits are not included in the fees described. If an afterhours or emergency visit is necessary, there is an additional fee of $75.00
End of Plan Fee Discounts – Patient acknowledges that fees where noted are discounted and not Network Family Wellness Center’s (NFWC) usual and customary per visit fees. Discount is applied at the end of care plan. Discount is lost if patient cancels or terminates care plan prior to end of plan of care.
Missed Appointments – It is the patient’s responsibility to keep all scheduled appointments in order to achieve the best results and to make up any missed appointments within the timeframe of this agreement. Please make up any missed appointments during the same week to keep your spinal correction on track.
Plan Not Insurance – This agreement does not constitute insurance and as such we make no promises to treat new conditions under this agreement.
Auto Accident, Work Injuries, New Conditions – In the event you are involved in an auto-related accident, on the job injury or develop a new health condition, this agreement will be suspended while you receive care at NFWC for the new injury or condition. Care provided for the injury or new condition will be at our usual and customary fees. Patient’s original care plan will be resumed after patient has recovered or been released by NFWC from the injury or new condition. Patient agrees to notify us within 72 hours of an auto or work-related injury or new health condition.
Early Termination of Agreement / Loss of All Discounts/Refunds – Patient understands that if they cancel care prior to the end of this agreement, patient’s account balance will be pro-rated based on the Pay Per Visit Fee of $50 per visit (plus any additional services rendered such as x-rays, examinations, nutritional supplements, etc.) for all services provided and ALL discounts will be lost.If a balance is due after account is adjusted, automatic monthly payments will still be drawn on scheduled due dates until balance is paid in full. Any overpayment will be refunded within 12 weeks of written notice of cancellation of care by patient to NFWC.
No Guaranteed Results - Patient recognizes that this agreement is not a guarantee of clinical results, and that this serves solely as a disclosure of financial and time obligations.
Use Visits Within Care Time Frame - Members must use all regular network visits within the agreed upon billing period. If all visits are not used within the agreed upon billing period, the visits will be forfeited. Exceptions may be made with previously agreed upon special circumstancessuch as extended travel when in writing and signed by Dr Knowles. Once beyond time frame of membership agreement no refunds or credit will be issued for any unused visits.
Extra Sessions Purchased – Extra visits may be purchased. All extra visits must be used on or before the membership expiration date.
Extra Sessions Acquired – Extra visits which are acquired (for referrals, gifts, etc.) must be used within 45 days of date of issue.
Membership Freeze Policy - Voluntary freezes may be arranged for a fee of $40 per month. Within a 12 month membership, you may elect a maximum of any 2 months for a voluntary freeze, with 30 days advance notice of your billing date. Your membership expiration date will be extended for the number of months you elect to freeze your membership. A membership any less than 4 months does not qualify for voluntary freezes.
Medical freezes are allowed with doctor’s orders. There is no fee for a medical freeze; however you must provide documentation from your doctor. Your membership will be extended for the number of months the membership is frozen.
Complete Agreement – This agreement is non-transferable and constitutes the complete agreement between the patient and NFWC. If there are any additional factors staff have mentioned they must be in writing. This agreement may be unilaterally modified by NFWC with 30 days’ written notice.
Purpose of Care – The purpose of chiropractic care is not to treat diseases or conditions, medically diagnose, nor to suppress symptoms, nor to perform surgery or prescribe medications, but rather to improve the health and function of your spine and nerve system to the maximum degree possible for you to help your body function at its highest potential.
Patient/Guarantors Name (Print) Patient/Guarantors Name (Signature) Date
When a patient seeks chiropractic health care and NFWC accepts a patient for such care, it is essential for both to be working for the same objective. It is important that each patient understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment. You have the right, as a patient, to be informed about the condition of your health and the recommended care and treatment to be provided so that you may make the decision whether or not to undergo chiropractic care after being advised of the known benefits, risks and alternatives.
Chiropractic is a science and art which concerns itself with the relationship between structure (primarily the spine) and function (primarily the nervous system) as that relationship may affect the restoration and preservation of health. Health is a state of optimal physical, mental and social well-being, not merely the absence of disease and infirmity.
One disturbance to the nervous system is called a vertebral subluxation. This occurs when one or more of the 24 vertebrae in the spinal column becomes misaligned and/or do not move properly. This causes alteration of nerve function and interference to the nervous system. This may result in pain and dysfunction or may be entirely asymptomatic.
Subluxations are corrected and/or reduced by an adjustment. An adjustment is the specific application of forces to correct and/or reduce vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine. Adjustments are usually done by hand but may be performed by handheld instruments. In addition, ancillary procedures such as physiotherapy and/or rehabilitative procedures may be included.
If you desire medical diagnosis or treatment for a specific symptom, disease or condition, or advice on taking or stopping medications, we recommend you consult a healthcare provider who specializes in that area.
We will let you know if we discover unusual findings during the course of our chiropractic examination(s). You may then decide whether you wish to investigate further and discuss your healthcare options with other health professionals. We will cooperate with you and them in achieving your health goals.
Acknowledgements of understanding – All questions regarding the doctor’s objective pertaining to my care in this office have been answered to my complete satisfaction. The benefits, risks and alternatives of chiropractic care have been explained to me to my satisfaction. I have read and fully understand the above statements and therefore accept chiropractic care on this basis. I have read, accept and agree to abide by the Terms and Conditions spelled out in this four page document and any attachments and addendums.
Patient/Guarantors Name (Print) Patient/Guarantors Name (Signature) Date
Center name HERERepresentative (Print) Center name HERE Representative (Signature) Date