Pain 2 Wellness Center

New Patient Forms - Not PI


I understand that this organization originates and maintains health records which describe my health history, symptoms,
examination, test results, diagnoses, treatment, and any plans for future care or treatment.
I understand that this information is used to:
▪ Plan my care and treatment
▪ Communicate among health professionals who contribute to my care
▪ Apply my diagnosis and services, procedures, and surgical information to my bill
▪ Verify services billed by third-party payers
▪ Assess quality of care and review the competence of healthcare professionals In routine healthcare operations

I further understand that:
▪ A complete description of information uses and disclosures is included in A Notice of Information Practices which can be provided to me at my request

▪ I have a right to review the notice prior to signing this consent
▪ The organization reserves the right to change their notice and practices
▪ Any revised notice will be mailed to the address I have provided prior to implementation
▪ I have the right to object to the use of my health information for directory purposes
▪ I have the right to request restrictions as to how my health information may be used Or disclosed to carry
out treatment, payment, or health care operations
▪ The organization is not required to agree to the restrictions requested
▪ I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon

I request the following restrictions to the use or disclosure of my health information:  

The above named patient authorizes the staff of Pain 2 Wellness Center, LLC to use and/or disclose protected health information in accordance with the following specific authorizations:

1. Contact Authorization. I give permission to Pain 2 Wellness Center to use the following information, but not limited to my: address, phone number, and clinical records to contact me with appointment reminders, missed appointment notification, birthday and any other holiday related cards, and to display a picture of my automobile accident on a bulletin board. If Health Authority contacts me by phone, I give them permission to leave a phone message on my answering machine or voice mail.

2. Open Room Authorization. I give Pain 2 Wellness Center permission to treat me in an open room where other patients are also being treated. I am aware that other persons in the office may overhear some of my protected health information during the course of care. Should I need to speak with the doctor or staff at any time in private, they will provide a room for these conversations.
3. Right to Establish Payment. I authorize and grant power of attorney to any approved agents of Pain 2 Wellness Center to act with any insurance company regarding claims, payment of my treatment, and collection for bills. This includes full permission to establish a medical or accident claim, on my behalf, and create payment protection that would relate to the payment of any healthcare services. Any statements or documents, related or affecting treatment services that would prevent or deny insurance payments to this office are to be made null and void by the receipt of this form. I intently grant an assignment of benefits as letter of credit against my insurance claim(s) for direct payment to this office. I further authorize the release of any information regarding my coverage on my insurance policy, or any future claim settlement status from the associated insurance
company(s) their attorney(s) and/or my personal attorney(s).

This authorization is requested by Pain 2 Wellness Center for its own use/disclosure of PHI. (Minimum necessary HIPPA standards apply.) You have the right to refuse to sign this authorization. If you refuse to sign this authorization, Pain 2 Wellness Center LLC, retains the right to refuse treatment or may offer to provide treatment on a pre-paid basis.

Patient Name:  

Parent/Guardian Signature:

Name of Custodial Parent or Legal Guardian, on Behalf of the Patient:  


Financial Policy

In an effort to maintain compliance with various state and federal regulations, managed care and preferred provider agreements, as well as billing and coding guidelines, we have adopted the following financial policies: Our clinic has established a single fee schedule that applies to all patients for each service provided. You may be entitled to a network or contractual discount under the following circumstances:
▪ If we are a participating provider in your health plan.
▪ If you are covered by a State or Federal program with a mandated fee schedule.
▪ We are a network provider in a Discount Medical Plan Organization (DMPO) that you may join. Patients who are uninsured, or underinsured (limited
benefits for chiropractic care). Ask our team for more information. DMPOs CANNOT BE USED FOR INJURY CLAIMS
▪ If you are eligible & choose a pre-payment plan, auto-debit plan or “prompt payment” option. We offer weekly, monthly, or yearly payment

As part of plans. our compliance plan, our office will be unable to extend any type of discounts other than those listed above. We are committed to providing you with the best chiropractic care possible in a caring environment and have established our financial policies to achieve that goal. Details of your care plan will be discussed with you during your Chiropractic Report. To assist you with your healthcare investment, we provide the following payment options:
• Cash - includes money orders and personal checks
• Credit Cards – MasterCard, Visa, and American Express
• Auto-Pay – an auto debit payment program that uses debit cards or credit cards

Health Insurance: If you have insurance that covers chiropractic, we will file all of the information for you. This includes your diagnosis, prognosis, and copies of your records or reports. Remember, you agreement with your insurance company is between you and them. If for some reason your insurance does not pay what we expect, you will be responsible for the balance. We file your insurance only as a courtesy for you. We will discuss this option with you during your Chiropractic Report. ALL DEDUCTIBLES AND CO-PAYMENTS must be paid prior to service. Special Situations: i.e. AUTO INJURY

If you choose to use insurance for a special injury claim, such as an auto accident or a workers compensation injury, your “normal insurance” or DMPO will be “frozen” until such claim is closed. Your personal “Health Insurance” is not required to pay “third party claims”. We will then continue on the corrective plan we have chosen for you at that time.
Office Fee Schedule

Medicare patients: Medicare offers very limited coverage for chiropractic treatment. Medicare does not cover X-ray examinations, physical examinations, extremity adjustments, hot/cold treatments, traction or other therapies performed by a Chiropractor. Medicare will only cover chiropractic spinal adjustments.

                                        SERVICE                                                              OFFICE FEE

                                        99201 – 99205 Initial Exam (Brief-Comp.)                 N/C-100
                                        99211 – 99215 Est. Re-Exam (Brief-Comp.)             $100-$250
                                        X-Rays (per view)                                                      $50-$20 BY REFERRAL
                                        98940 Adjustment (1-2 regions)                                 $51
                                        98941 Adjustment (3-4 regions)                                 $63
                                        98942 Adjustment (5 plus regions)                             $75
                                        98943 Adjustment (extremities)                                  $40
                                        97035 Ultrasound 15 minutes or less                         $45
                                       97014 Electric Stimulation 15 minutes or less             $40
                                       97012 Mechanical Traction 15 minutes or less           $50
                                       97110 Therapeutic exercises 15 minutes or less          $65
                                       97530 Therapeutic procedures 15 minutes or less       $60
                                       97535 Self Care Home Therapies 15 minutes or less   $77
                                       Wellness & Corrective Adjustment Plans Patient           Based on individual needs

Statement of Understanding: 
I have read the codes and fees and understand the cost of my care with my treating doctor. I understand that I am responsible for payment of all deductibles and co-payments related to my care. I understand that if I have a balance for medical services not paid, I will make a minimum of $50.00 each month or 20% (auto-debit) of the outstanding balance whichever is greater. If my balance is not paid in a timely and monthly fashion, I promise to pay any and all service, collection, court, and attorney fees in the collection of my account. I further understand that if my treatment is associated with a personal injury or accident claim, all medical bills will be paid at 100% of the above fee schedule regardless of the outcome of my case. I also agree to Pain 2 Wellness Center filing a lien against the settlement of aforementioned case. I am aware that if my case is not settled 90 days after the end of treatment my account will be placed in collections. I understand that if a check or debit is returned for insufficient funds, I will be charged a $25.00 service charge. I further understand that if my insurance company declines payment, I authorize Pain 2 Wellness Center to file small claims on my behalf against my insurance company as a method of collection. I further understand that I will be present at the court date if needed. I have read and fully understand the above financial terms, policies, and prices. 

Patient Name:  

Parent/Guardian Signature:

Name of Custodial Parent or Legal Guardian, on Behalf of the Patient:  


Office Policies and Procedures
In order to provide the best care for our patients, all patients are accepted for care based in the following policies:
 (Initial) Office Hours: Monday, Wednesday, Thursday, and Friday, our office will open promptly at 9:00 am. We close daily 1:00-3:30 to allow time for staff meetings, trainings, and lunches. We close for the day 7:00 pm, with the exception of Thursday, where we will close at 1:00 pm Our last appointment is accepted 30 minutes before each closing time. We are closed on Tuesdays.
  (Initial) Treatment Plans: Care plans are individualized for each patient based on their individual needs, goals, and condition of their spine. It is the responsibility of the patient to follow their treatment plan to receive the full benefits of their program. Changes to treatment plans or visit frequency will be made at specific re-evaluations based on progress. Please understand that we do not base your care plan on your extended insurance coverage, and neither should you. There are limits to what they will pay. Our goal is to correct your problem in the shortest amount of time possible and in the most cost-effective manner. You will achieve the best results when you follow the practitioner’s recommended appointment schedule and home care advice. Remember: healing takes time. If you do not feel satisfied with your body’s responses, please request extra time for your next appointment to discuss this with your practitioner. We want you to get the most from your care.
(Initial) Back Office: Our patient’s treatment and privacy are of upmost importance to our office. To stay in compliance with our privacy policies, we ask all patients to please refrain from entering the treatment area without assistance from the staff.
(Initial) Reading of Reports: If you have completed the recommended MRI or other imaging, please inform the front desk so that they may schedule a time for you to go over those results with the doctor. Remember to bring in your MRI disc provided to you at the time of your appointment.
(Initial) Medical Record and Forms: Copying and transfer of medical records requires a signed release by the patient. There is a pre-payment required before records can be copied. The fee to pick up your medical records is $25. If you want your medical records mailed, the fee is $28. Once payment is received, please allow up to 7 business days to prepare and mail records. If you would like to pick them up, we will contact you once they are ready. If you require services, documents or documentation that fall outside of our normal office visit procedures, such as: letters of medical necessity, or work equipment requests, please allow a minimum of five business days for response and/or receipt of the requested information. Due to the required time, the doctor may charge a fee of up to $200 per set of forms.
(Initial) New Patient Orientation: It is required that all patients watch “New Patient Orientation” health workshop. This workshop will be sent to you via email.  We have found that the patients who follow this recommendation GET BETTER FASTER AND SPEND LESS MONEY.
  (Initial) Personal Injury Patients: Personal injury patients must stay consistent with adjustments and notify the office of any changes with adjusters or attorneys. Personal injury patients will be billed in the following order:
1. 1st Party-Med pay – Patient auto insurance
2. 3rd Party Liability – At fault party (must have Attorney representing)
3. Under or Uninsured Motorist – Patient’s auto insurance
4. Personal Health Insurance – Must have proof that all other venues have been exhausted

X Ray Consent: During your examination, the doctor may feel that x-rays will be needed in order to diagnosis your condition. We would like to make you aware that x-rays may be required in order to administer treatment. Before we perform x-rays on any patient our office requires the patients consent for such tests to be performed.
Please read the statements below and select ONE choice Do not initial both.
  (Initial) I understand that my doctor may need x-rays in order to diagnosis my condition and I give permission of all needed diagnostic tests.
(Initial) I understand that my condition may require my doctor to take x-rays to further diagnosis my symptoms. I choose NOT to have any x-ray at this time and release my doctor of all liabilities.

FEMALES ONLY: I understand that if I am pregnant and have x-rays taken which expose my lower torso to radiation, it is possible to injure the fetus. I have been advised that the ten (10) days following onset of a menstrual period are generally considered to be safe for x-ray exam. With those factors in mind, I am advising my doctor that I am not pregnant. (Initial)

Our clinic reserves the right to deny services to anyone for any reason, or if the doctor feels that the patient’s health is not being best served.

Statement of Understanding: I have read and fully understand the above terms and office policies listed above.

Patient Name:  

Parent/Guardian Signature:

Name of Custodial Parent or Legal Guardian, on Behalf of the Patient:  




We, at Pain 2 Wellness Center understand that sometimes you need to cancel or reschedule your appointment and that
there are emergencies. If you are unable to keep your appointment, please call us as soon as possible (with at least a 24-
hour notice). You can cancel appointments by calling the following number: 404-699-0966 or via email at
To ensure that each patient is given the proper amount of time allotted for their visit, short wait times, and to provide the
highest quality care, it is very important for each scheduled patient to attend their visit on time. As a courtesy, an
appointment reminder text to you is made/attempted one (1) business day prior to your scheduled appointment.
However, it is the responsibility of the patient to arrive for their appointment on time.

1. If less than a 24-hour cancellation is given this will be documented as a “No-Show” appointment.
2. Any “No-Show/Missed” appointments will be assessed a $25.00 no show fee. This fee is not covered by
insurance or any personal injury case and must be paid prior to your next appointment.
3. If you arrive more than 15 minutes past your scheduled appointment time you may still be seen if our schedule
permits. You will be moved to a walk in. This could result in longer wait times as patients with scheduled
appointments will be seen first.
4. Multiple “no shows” in any 6 month period may result in termination from our practice.

Cell Phone Usage Policy

Pain 2 Wellness Center is a place of healing. In order to allow all patients proper relaxation, we require all phones be
placed on silent upon entering the office. This includes all notification and any videos. If you receive an emergent call, we
ask you take our call outside. Once you have completed your call, please inform the front desk staff so that the staff will
know you are ready to begin treatment. If you are unavailable, staff will move on to the next patient.

I have read and understand Pain 2 Wellness Center’s No Show/Missed/Late Appointment Policy and “Cell Phone Usage
Policy” and understand my responsibility to plan appointments accordingly and notify Pain 2 Wellness Center
appropriately if I have difficulty keeping my scheduled appointments.

Patient Name:  


Patient Signature:  or Parent/Guardian if minor Relationship to Patient: 

I have read this entire document and fully understand & irrevocably agree to it.

Printed Name:  


Relationship to Patient:  


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Document name: New Patient Forms - Not PI
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Timestamp Audit
October 14, 2020 12:48 pm ESTNew Patient Forms - Not PI Uploaded by Winston Carhee - IP
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