Privacy and Sharing of Information

I authorize the clinic and its associated health professionals to collect my personal and medical information as documented above. In addition, I authorize the clinic and its associated health professionals to communicate with my family doctor and/or referring doctor as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.

Financial & Insurance Policy

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.

PATIENTS: Payment is expected in FULL at each visit.

PATIENTS WITH INSURANCE: You will be seeing our doctors as an “out of network” provider. You may request a medical itemized receipt , AKA “Superbill”, so that you may submit to your insurance company for any out-of-network reimbursement.

PATIENT BILLING & BALANCES DUE: Please be aware that the balance of your services is your responsibility at time of service. In the event that you do not pay your balance in full, we will charge the credit card on file for such patient responsibility to the following extent: 1. 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. 2. 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. 3. 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. 4. 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. The following therapies will not be billed to insurance and will be charged as an out-of-pocket procedure:Instrument Assisted Soft Tissue Manipulation (aka Graston), Kinesiology Taping, Massage, Neuromuscular Re-education, laser, traction table (aka roller table), and decompression.

MEDICARE PATIENTS: We accept Medicare and bill claims as a non-participating provider which means we collect payment for services rendered at time of service. We will bill your claim to Medicare for you and you will receive reimbursement from Medicare directly. 

*For supplemental or replacement plan questions please call us at 913-730-1800

No Show/Cancellation/ Late Arrivals Policy

NO SHOW/CANCELLATION/LATE ARRIVALS: Patients must give a 24 hour notice to cancel or reschedule your appointment, otherwise a $45.00 missed or change appointment fee will be collected automatically. Each patient will receive one verbal or written warning before they are charged.

LATE ARRIVALS: Patients are allowed to be up to 7 minutes late, without needing to reschedule. We will utilize the remaining time of your appointment, if the practitioner can do the therapy in the reduced time, for the full fee of service. Any scheduled services that cannot be completed in the reduced time, must be rescheduled for another appointment time, and MAY incur an additional charge.

How to Cancel Your Appointment

If you need to cancel your appointment, please call us at (913) 730-1800. If necessary, you may leave a detailed voicemail message. We will return your call as soon as possible. You can also manage your appointments by login into your patient profile here

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