It is the policy of this office that all services rendered are the responsibility of the patient, and that you are ultimately personally responsible for all payments, regardless of whether or not this office accepts insurance assignment.
PATIENTS WITHOUT INSURANCE OR SELF PAY: If you are not insured OR not insured by a plan we participate with, payment is expected in FULL at each visit. If you are seeing our doctors on an “out of network” basis you may request a “Superbill” so that you may submit it to your insurance company for out-of-network reimbursement.
PATIENTS WITH INSURANCE: Vitality Chiropractic and Family Wellness, LLC (VCFW) participates with Blue Cross Blue Shield and United Health Care. Knowing your chiropractic insurance benefits is your responsibility. All co-payments and deductibles must be paid at the time of service. PATIENT BILLING & BALANCES DUE: Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. In the event that you do not pay your co-payment or deductible payment at the time of service OR your insurance carrier assigns any additional patient responsibility amounts after the claim is processed, we will charge the credit card on file for such patient responsibility, co-payment or deductible amount to the following extent:
1. If the balance due is less than $100 your card will be charged automatically.
2. If the balance due is greater than $100, we will contact you 72 hours prior to your card being charged. Should you decide to use an alternate method of payment OR set up a payment plan, please alert our office within 72 hours of our contact, and our contact shall include a voice message from us to you if we are unable to reach you.
3. Payment plans ARE available upon request.
4. A $10 late fee per month may be charged to your account if your balance is unpaid 90 days after your last visit until balance is paid in full.
5. If we do not receive payment in full for the balance due, or you have not set up an automatic payment plan after 6 months of an unpaid balance your account may be forwarded to collections, and you hereby agree that if VCFW, LLC places your account with an agency or attorney for collection, you will pay VCFW, LLC all of its costs and expenses in collecting monies owed by you to the extent allowed by applicable law.
6. If your credit/debit card on file expires or otherwise becomes uncollectible, we will expect you to promptly provide a new credit or debit card.
7. A $25 returned check fee will apply towards your account for checks returned for insufficient funds.
NON-COVERED SERVICES: Please be aware that some of the services you receive may not be covered or not considered reasonable or necessary by Medicare or other insurers. You are responsible for payment of these services.
ASSIGNMENT OF BENEFITS: I, the undersigned certify that I (or my dependent) have coverage with my insurance as presented and assign directly to VCFW, LLC all insurance benefits, payable to me for services rendered, I understand that I am responsible for payment of deductibles, co-payments, and/or non-covered services, I hereby authorize the doctor to release all information necessary to secure payment of benefits. I authorize RELEASE OF MEDICAL INFORMATION to my insurance carrier, or requested physician to provide continuity of care. I authorize the use of this signature on all insurance submissions. I acknowledge and understand that it is my responsibility to inform the doctor’s office if there is a change in my health insurance information.
PATIENT ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES: I consent to the use or disclosure of my medical information by Vitality Chiropractic and Family Wellness, LLC and/or the affiliate practitioners that operate within Vitality Chiropractic and Family Wellness, for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of VCFW. I understand that diagnosis or treatment of me by VCFW may be conditioned upon my consent as evidenced by my signature on this document. I understand I have the right to request a restriction as to how my medical information is used or disclosed to carry out treatment, payment or health care operations of the practice. VCFW is not required to agree to the restrictions that I may request. However, if VCFW agrees to a restriction that I request, the restriction is binding on VCFW. I have the right to revoke this consent, in writing, at any time, except to the extent VCFW has taken action in reliance on this consent.
My “medical information” means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This medical information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me. I understand I have a right to review VCFW’s Notice of Privacy Practices prior to signing this document. A current copy is posted in the lobby of Vitality Chiropractic and Family wellness.
The Notice of Privacy Practices describes the types of uses and disclosures of my medical information that will occur in my treatment, payment of my bills or in the performance of health care operations of VCFW. This Notice of Privacy Practices also describes my rights and the duties of VCFW with respect to my medical information. VCFW reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.
Missed Appointment Policy
Our goal is to provide quality health care to all our patients in a timely manner. No-shows, late arrivals, and cancellations inconvenience not only our providers, but our other patients as well. Please be aware of our policy regarding missed appointments.
When you book your appointment, you are holding a space on our calendar that is no longer available to our other patients. In order to be respectful of your fellow patients, please call our office as soon as you know you will not be able to make your appointment.
If cancellation is necessary, we require that you call at least 24 hours in advance. Appointments are in high demand, and your advanced notice will allow another patient access to that appointment time.
How to Cancel Your Appointment
If you need to cancel your appointment, please call us at (913) 730-1800 between the hours of 9:00am – 6:00pm. If necessary, you may leave a detailed voicemail message. We will return your call as soon as possible.
Late Cancellations, Late Reschedule or No-Shows
A late cancellation and/or late reschedule is considered late when the appointment is canceled or rescheduled less than 24 hours before the appointed time. A no show is when a patient misses an appointment without canceling. In either case, we will charge the patient a $35.00 missed appointment fee.
For new patients’ first appointments, a no show or late cancellation will result in a full charge of the new patient fee.
Chiropractic evaluation and treatment involves certain inherent risks. There are several benefits associated with performing an evaluation. They include: working diagnosis of present condition, qualifying physical abilities and comparing performance results with the physical demands of a specific job category or classification. There are also expected benefits associated with participation in a treatment program. They include: increased flexibility, decreased pain, decreased inflammation, better circulation; all combining to improve function in activities of daily living.
Today’s treatment may involve adjustments, interferential current therapy, intersegmental traction therapy, active or passive stretching, instrument-assistant soft tissue manipulation (IASTM), massage techniques (including but not limited to effleurage, petrissage, compression, and tapotement) and the application of kinesiology tape. Risks may include but are not limited to cardiovascular, muscle, ligament, joint, disc injury, reddening of the skin and/or development of petechiae (small broken capillaries in the skin’s surface), bruising, itching and/or blistering of the skin, muscle, ligament, or joint injury. Symptomatic aggravation of the condition is also possible. Risk factors have been reduced to the best of our ability to ensure the maximum improvements. However, any increase in the current level of discomfort, or any other change in symptoms should be immediately reported to Dr. Jimenez.
Adjustment – Spinal manipulation that involves precise impulses in a specific direction to restore normal motion and position of individual vertebrae.
Interferential Current Therapy – Small electrical impulses are used to stimulate muscles and relieve tension by reducing nerve irritation. This current promotes the secretion of natural painkillers (endorphins).
Intersegmental Traction Therapy – This therapy utilizes rollers that slowly travel the length of the spine. By stretching individual joints, it promotes increased mobility and blood flow that leads to faster healing.
Active or Passive Stretching – Areas of the body taken through active or passive range of motions to encourage stretching and lengthening of the muscles and increased circulation.
Instrument-Assisted Soft Tissue Release (IASTM) – A treatment to break up adhesions or scar tissue detected by the stainless steel instrument in the area of complaint to increase range of motion, decrease pain, improve circulation, encourage healing, and prevent the formation of the development of scar tissue.
Massage Techniques – Including but not limited to effleurage, petrissage, compression, and tapotement techniques to encourage muscle relaxation, stretching and lengthening of the muscles and increase circulation.
Kinesiology Taping – The application of elastic adhesive tape to the area of complaint to help eliminate pain, aid in proper muscle and joint function, provide support and neuromuscular re-education.
Risk factors have been reduced to the best of our ability. Please acknowledge consent with full knowledge of the nature, risks, and purpose of the evaluation and treatments.
DO NOT RECEIVE TREATMENT IF YOU HAVE ANY OF THE FOLLOWING: AN INFECTIOUS OR CONTAGIOUS SKIN DISEASE, OR INFLAMMATORY CONDITION AFFECTED BY INCREASED BLOOD CIRCULATION.