Patient Policy Procedures

1. A treatment schedule is provided to assist the patient in attaining the best results in the quickest time possible.
2. Treatment schedules are revised every 30-90 days based on the progress of the patient.
3. If the patient fails to call and cancel their appointment, a cancellation fee may be added to patients account.
4. A missed appointment will be made up within seven (7) days to keep the patient on optimal treatment protocol.

Financial Policy and
Authorization to Provide Medical Services and Treatment

1. Patient hereby authorizes The Back Expert, P.C.(dba: Total Wellness Center) to treat specific illnesses or injuries related to spinal misalignments, nutrition, and to perform other such
   health related services.
2. The Back Expert, P.C. will submit all necessary paperwork to patient's insurance company as a courtesy. Patients acknowledges that some, if not all, of the services provided by The Back Expert, P.C. may not be paid by patient's insurance company or maybe paid at a reduced rate.
3. Patient acknowledges that patient ( or the patients legal guardian or parents) are ultimately responsible for fees incurred by The Back Expert P.C. as a result of service rendered and performed.
4. Patient acknowledges any account balance(s) that are not paid within 150 days from the date of service may be forwarded to collections agency. Account balances not paid within 150 days will bear interest at the rate of 1.5% per month (18% per annum). Should litigations become necessary to collect an amount owed, the patient or responsible party agrees to pay all costs of collections including, but not limited to, collection fees, attorneys fees, interest and court costs.
5. Patients acknowledges that should The Back Expert, Inc. file a lawsuit for
   collection of any past due balances, venue of the lawsuit will be in the County of Arapahoe.
   

AUTHORIZATION OF ASSIGNMENT

I hereby authorize and direct any and all insurance carriers, attorneys, agencies, governmental departments, companies,individuals, and/or other legal entities, which many elect or be obligated to pay, provide, or distribute benefits to me for any medical conditions, accidents, injuries, or illnesses, past, present, or future ("conditions") to pay directly and excessively in the name of Total Wellness Center ("office") such sums be owing to Total Wellness Center for charges incurred by me at the office relating to my condition, with such payments to be made exclusively in the name of Total Wellness Center. I further grant a lien to Total Wellness Center with respect to my charges. This lien shall apply to all payers and to the full extent permitted by law. For the purpose of this document (herein, "Assignment and Lien"), benefits shall include, but not be limited to, proceeds from any settlement, judgment or verdict, as well as any proceeds relating to commercial health or group insurance, attorney retainer agreements, medical payments benefits, personal injury protection, no-fault coverage, uninsured and underinsured motorist coverage, third party liability distribution, disability benefits, worker's compensations benefits, and any other benefits or proceeds payable to me for the purposes stated herein.

In the event that I retain one or more attorneys to represent me in this matter who are not located in Colorado, I will direct each attorney to issue a letter of protection to this office regarding my charges. Upon issuance, I hereby agree that such letter(s) of protection cannot be revoked or modified without the expressed written consent of this office.

I authorize this office to release any information regarding my treatment or pertinent to my case(s) to all payers as defined above to facilitate collection under this Assignment and Lien. I further authorize and direct all payers to release to Total Wellness Center any information regarding any coverage or benefits which I may have including, but not limited to, the amount of coverage and the amount paid thus far, and the amount of any outstanding claims. I hereby direct this office to file a copy of this Assignment and Lien, together with any applicable charges, with any and all payers, regardless of whether a claim has been established with said payers. I hereby authorize Total Wellness Center to endorse/sign my name on any and all checks listed to me as a payee which are presented to this office for payment of an account related to me, my spouse or any of my dependents. I further authorize Total Wellness Center to apply any credit balances on charges incurred by me any other outstanding charges still owed by me, my spouse, or my dependents, regardless of these other charges are related to my condition.

I understand that in the event any of the above defined payers were to pay me directly, and not make payments directly to Total Wellness Center, I will be held personally responsible for the total amounts due Total Wellness Center for their services.

This Assignment and Lien shall not be modified or revoked without the mutual written consent of Total Wellness Center and myself. I hereby revoke any previous signed authorizations, whether executed at this office or any office to the extent that the terms of those authorizations conflict with the terms of this Assignment of Lien.

NOTICE OF PRIVACY PRACTICES
(MEDICAL)
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY!

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal program chat requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept: properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities chat misuse personal health information.

As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of you health information and how we may use and disclose your health information.

We may use and disclose your medical records only for each of the following purposes: treatment, payment, and health care operations.

• Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would include a physical examination.
• Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment.
• Health Care Operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-managemeni: analysis, and customer service. An example would be an internal quality assessment review.

We may also create and distribute de-identified health information by removing all references of individually identifiable information.

We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services chat may be of interest to you.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing, to which we are required to honor and abide by, except to the extent thac we have already taken actions relying on your authorization.

You have the following rights with respect to you protected health information, which you can exercise by presenting a written request to the Privacy Officer.

• The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
• The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
• The right to inspect and copy your protected health information.
• The right to amend your protected health information.
• The right to receive an accounting of disclosures of protected health information.
• The right co obtain a paper copy of this notice from us upon request.

We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protect health information.

This notice is effective as of this date being today and upon your acceptantce by selcting the "SUBMIT" button at the bottom of this page. We are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effectives to all protected health information that we maintain. We will post changes and you may request a written copy of a revised Notice of Privacy Practices from this office.

You have recourse if you feel that your privacy protections have been violated. You have the right co file a written complaint with our office, or with the Department of Health and Human Services: Office of Civil Rights about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.

For more information about HIPAA:
Or to file a complaint:
The US. Department of Health and Human Services
Office of Civil Rights
200 Independence Ave., S.W.
Washington, D.C. 20201
Or Call: (202) 619-0257
Toll Free: 1-877-696-6775