Terms of Acceptance



When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective.


Chiropractic has only one goal. 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.


Adjustment: An adjustment is the specific application of forces to facilitate the body’s correction of vertebral subluxation (misalignment). Our chiropractic method of correction is by specific adjustment of the spine. Chiropractors also adjust articulations of the extremities upper: shoulders, elbows, wrist, fingers; lower: knees ankles and toes.


Health: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity.


Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of the nerve function and interference of the transmission of mental impulses, resulting in a lessening of the body’s innate ability to express its maximum health potential. (Also misarticulating extremity joints that cause nerve interference).


We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic examination, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area.


Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body’s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations.


I, have read and fully understand the above statements.


All questions regarding the doctor’s objectives pertaining to my care in this office have been answered to my complete satisfaction.


I therefore accept chiropractic care on this basis.





(Signature)  Below                                                                                                  


3910 Cascade Road SW, Suite A

Atlanta, GA 30331


Fax 404-699-0988

Office Fee Schedule and Financial Policy


                        Service                                                            OFFICE FEES

            Consultation                                                                            N/C-100

            99201 – 99205           Initial Exam (Brief-Comp.)                 $100-$250

            99211 – 99215            Est. Re-Exam (Brief-Comp.)              $50-$200

            X-Rays                                                                             $25 - $120

            98940  Adjustment     (1-2 regions)                                        $51

            98941              “          (3-4 regions)                                        $63

            98942              “          (5 plus regions)                                    $75

            98943              “          (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               Based on individual needs


Patient 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 Signature  Below                        



Financial Policy and Corrective Adjustment Plans  


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 DMPO that you may join. Patients who are uninsured, or underinsured (limited benefits for chiropractic care), will be entitled to network discounts similar to our insured patients. Membership is $49.00 a year and covers you and your dependents. Ask our team for more information.
  • If you are eligible & choose a pre-payment plan, auto-debit plan or “prompt payment” option.
  • Patients who meet state and or federal poverty guidelines or other special circumstances outlined in our “Hardship Policy” may be offered a discount for a period of time as determined by the clinic. Verification will be required.

As part of our compliance plan, as of 8/28/2017 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

We offer weekly, monthly, or yearly payment plans.

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 OR WORKERS COMP

If you choose to use insurance for a special injury claim, such as an auto accident or a workers compensation injury, your “normal insurance” 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.

Order of Insurance Filing

  1. 1st Party-Med pay – Patient auto insurance
  2. 3rd Party Liability – At fault party (Attorney)
  3. Under or Uninsured Motorist – Patient auto insurance
  4. Personal Health Insurance – Patient health insurance


I have read and I understand the above policies.




 Permission to Request Police Report                              

I  give Pain 2 Wellness permission to retrieve my police report from

www. Buy Crash.com to only serve as documents needed in order to fulfill my motor vehicle collision case.

Information needed to obtain police report:


Date of Birth:   

Date of Accident:  

Drivers License Number#  


Extension of Credit, Lien and Assignment of Benefits


*In consideration for this office providing services to me, and because I do not have sufficient funds available to pay in advance for care; I hereby seek credit and grant a lien to this office against any and all proceeds resulting from and arising out of the negligence of a third party, causing injuries and the need for reasonable and necessary health care, which this office, shall provide. Because services are to be rendered in reliance upon this agreement, I agree this agreement shall be irrevocable after being signed. In the event I change or substitute my attorney, this lien shall be binding upon any subsequent attorney upon being furnished a copy of this agreement. This shall not imply that the services are being provided on a contingency basis. I direct any insurance company, attorney or other person who holds or later holds proceeds from my claim to apply it directly to my account at this clinic.   


*If using an attorney, now or in the future, I irrevocably direct them to follow State Bar of Georgia - RULE 1.15(I) SAFEKEEPING PROPERTY – GENERAL, and direct them to honor all debts to this clinic. They can negotiate for me but my attorney is not to release funds directly to me without honoring this debt.  My lawyer has a duty under applicable law to protect such third-party claims against wrongful interference by their client (me), and accordingly may refuse to surrender the property to me until an agreement is made concerning my debt to this clinic. If my attorney does not honor this agreement they will be in violation of Georgia Bar Rule 1.15(I).


*I also authorize and direct my attorney to sign any liens or letters of protection from this office.


Assignment of Benefits and Direct Payment:                                                                                             

*I direct my attorney, insurance company or claims adjuster, to pay any outstanding bills out of my settlement or med pay benefits, in effect; protecting any such balance and pay this money DIRECTLY to this office.  I assign proceeds from my claim to PAIN 2 WELLNESS CENTER, LLC., (Tax 020-72-1783) to pay for treatment and services rendered by this Clinic. I irrevocably request and direct that payment be sent directly to this clinic.                    

*I further personally guarantee payment to this office against the proceeds of any settlement, judgment or verdict. If the case does not settle the debt is still due. I also understand that I am responsible for all collection and court cost associated with collecting this debt. Payment is not contingent on receipt of a settlement.  I realize that I am responsible to make sure payment is made to your office and I will update your office once a month concerning the status of my case.                             


I hereby authorize and direct my insurance company, insurance administrator or attorney to pay by check, and for it to be mailed directly to our office the expense benefits allowable, as payment toward the total charges for professional services rendered.  I agree to pay, in a current manner, any balances of said applicable charges.  I agree that this office be given power of attorney to endorse any and all drafts for payment of my bill.  I understand and agree that health and accident insurance policies are an arrangement between an insurance carries and myself.  I permit this office to endorse remittances for the conveyance of credit to my account.  All co pays and deductibles are due at the time of service. I understand that I will be responsible for all collection or court fees involved if the account has to be sent to collections.


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




Patient Signature Below     Date:


By signing above, the co-payment and/or

Deductible for my chiropractic treatment

Would be a financial hardship on me.







Patient Goals




­__ Auto Accidents , __Workers Compensation, __Whiplash, __ Headaches, __Neck Pain, __Back Pain, __Disc Problems , __Sciatica, __Fibro-Myalgia, __Carpel Tunnel, __Scoliosis __Stress



Vertebral- [Ver-te-bral] concerning the vertebral bones of the spine.

Subluxation- [Sub-lux-a-tion] Less than a complete dislocation of a joint with nervous system interference.

“Vertebral Subluxation Complex” is the underlying cause of many health problems.



Problems with repetitive movements such as lifting, pushing, pulling, and sweeping, digging, bending or twisting can be improved. Carrying weights on one shoulder or one hip should be periodically redistributed or a backpack or other method can be used. Posture correction and implementation of ergonomic work stations. Avoid working in a seated position with elbows unsupported as it places significant strain on trapeziums, scalene and other frequently injured muscle groups.     


Good nutrition, exercise, chiropractic care, and other preventive measures are part of a wellness lifestyle. While chiropractic care can help with the integrity or your nervous system, remember the emotional and spiritual aspects of true wellness. A wellness approach to better health means adopting a variety of healthy habits for optimum function on all levels-physical, mental, social, and spiritual.



Proper nutrition, accompanied by exercise, posture, rest and periodic spinal adjustments, is a key to preventive health care. The over consumption of foods high in fat, cholesterol, refined and processed sugars, salt and alcohol increases the probability of suffering from cardiovascular diseases, diabetes and some forms of cancer.

That is why at Pain 2 Wellness Center we suggest specific nutritional supplements for each patient. Ask for your specific nutritional assessment TODAY.

The lumbar spine is the most frequently injured area of the spine. Sports injuries among youngsters are often ignored as “growing pains”. Regular chiropractic checkups can help avoid problems seen later in adults. Help prevent sports injuries by proper stretching, warm-up and cool-down exercises, and by staying fit. Proper spinal function is essential for peak performance at work or play.

The general population is going to chiropractors in record numbers. Seniors, the fastest segment of the population is no exception. A recent study published in Topics in Clinical Chiropractic of a randomized clinical trial showed data that found chiropractic geriatric patients were "less likely to have been hospitalized, less likely to have used a nursing home, more likely to report a better health status, more likely to exercise vigorously, and more likely to be mobile in the community."


Print Name              Date





Medical Records Request and Authorization


I request that Pain 2 Wellness Center have access to the following medical records in order to provide the best health care possible.                        


Please list below the names, addresses, and phone numbers of ALL the doctors you have visited:


Name                          Address                                                          Phone Number


__/ _/_

__/ _/_

__/ _/_

__/ _/_

__/ _/_

__/ _/_



       3910 Cascade Road SW

Atlanta, Georgia 30331

(404) 699-0966

Fax: 404-699-0988



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 has been provided to me

  • 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.


Patient Signature Below




Signature of Legal Representative                                 Date       

HIPPA Disclosure





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Signature Certificate
Document name: Terms of Acceptance
lock iconUnique Document ID: 93b653dc77d4f078b6f1da86e7d3ce60db19198f
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July 29, 2015 11:46 pm EDTTerms of Acceptance Uploaded by Winston Carhee - winston@carhee.com IP
October 20, 2020 10:21 am EDTApril Lima - office@www.pain2wellness.com added by Winston Carhee - winston@carhee.com as a CC'd Recipient Ip:
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November 4, 2020 3:29 pm EDTApril Lima - office@www.pain2wellness.com added by Winston Carhee - winston@carhee.com as a CC'd Recipient Ip:
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