Office Policies and Fee Schedules Procedure Adjustment 1-2 region Adjustment 3-4 region Extremity Adjustment NP-Exam-Focused NP Exam-Expanded NP Exam-Detailed NP Exam-Comprehensive EP Exam - Brief EP Exam – Intermediate EP-Exam-Detailed EP-Exam-Comprehensive Cervical X-ray (2 view) Cervical X-ray (Davis 5) Lumbar X-ray (2view) Rehab- Active (CTX/WOB) Muscle Stim with Laser Mechanical Traction Myofascial Release Neuromuscular Release Massage (Unit) Consultation Report of Findings Health Workshop Third party Consultations Narrative Reports Office Code CPT Code ADJ1-2 98940 ADJ3-4 98941 ADJEX 98943 IOV-Focused 99201 IOV Expanded 99202 IOV -Detailed 99203 IOV Comp 99204 PE Brief 99212 PE Int 99213 PE-Detailed 99214 PE-Comp. 99215 CXR2 72040 CXR5 72050 LXR2 72100 CTX/WOB 97110 EMS 97032 F/D 97012 97140 97140 NEURO 97112 MASS 97124 CONSULT ROF 99401 HCW 99412 Retail Fee $60 $75 $50 $85 $100 $125 $150 $85 $110 $135 $160 $70 $175 $114 $50 $50 $40 $32 per unit $45 $18 per unit $50 $53 $53 $350.00 per hour $350.00 to $1050.00 depending on complexity Initial office visits are billed at the retail rates until a care plan is prescribed and financial arrangements are made. *Returned checks will be assessed a $20 charge plus any bank imposed fees. *Missed appointments with no notice will be assessed a $25 charge per occurrence. *Missed Appointments with no notice for Acupuncture & Massage will be assessed half (1/2) the appointment fee. I hereby agree that I have read and understand “Office Policies and Fee Schedule” and that I accept its terms. I also agree that I will abide by these policies and do whatever might be necessary to effectuate them. I further acknowledge that ProSpine Chiropractic, LLC is a Colorado corporation and is governed by the venue of the state of Colorado. I understand that my signature below is sufficient as same for all billing inquiries and actions as necessary for office to seek full reimbursement from my (or 3rd Party) insurance carrier. I authorize ProSpine Chiropractic, LLC to conduct all actions necessary to seek reimbursement for services rendered to me. ____________________________________________ Signature of Practice Member ____________________________________________ Signature of Legal Guardian (if necessary) ________ Date ________ Date Office Policies Our purpose is restoring the natural expression of health you were designed to have….getting you back to what you love doing in life through natural Chiropractic care! We maintain a scientific and predictable approach to the correction of subluxation. In order to determine the appropriate level of Chiropractic care and whether we can accept your case, we ask that you agree to our initial process of evaluation and necessary recommendation. Payment: Payment is due at the time services are rendered. All first day procedures are to be paid for in full. We accept Visa, Master Card, personal check, and cash. Insurance and Personal Injury: We will gladly contact your insurance carrier or claims adjuster to verify coverage for Chiropractic care. We gain the best information possible from your carrier; however your policy is a contract with them and not our office. Therefore, there is no guarantee of benefits for services rendered. We always recommend that you contact your own carrier for your own contractual understanding. As the patient in our office, you are always responsible for charges and outstanding balances. Worker’s compensation: The state compensation insurance fund provides for payment of chiropractic services for treatment of accidental injuries that occur during the course of employment. It is necessary for you to have verification from your employer before you receive any treatment in this office. You will be provided with an “Authorization for Treatment” form. Please be aware that in the case that the form cannot be completed before treatment, a verbal authorization from a supervisor is required for this office to proceed with any treatment. We appreciate this opportunity to serve the health needs of you and your family.