Your attendance at the Wellness Orientation Workshop (W.O.W) is a pre-requisite requirement to be eligible for our discount programs of care. If you choose the 30% down option, we will schedule your remaining payments to be automatically deducted from your bank account or charged to your HSA, FSA, Visa, MasterCard, American Express or Discover Card.
Recurring Payments Will Make Your Life Easier:
- It’s convenient (saving you time waiting at reception every visit, and postage- no need to mail us a check every month)
- Your payment is always on time (even if you’re out of town), eliminating late charges
Here’s How Recurring Payments Work:
You authorize regularly scheduled charges to your checking/savings account or credit card. You will be charged the amount indicated below each billing period until the designated expiration date. A receipt will be emailed for each payment and the charge will appear on your bank or credit card statement. You will receive prior-notification 5 days before payment is due unless the date or amount changes, in which case you will receive notice from us at least 10 days prior to the payment being collected.
Terms and Conditions
Your signature on both the electronic and paper documents indicates you have read, understood, and agree to the terms and conditions regarding chiropractic care and recurring payments. You will be given a copy of the Discount Program terms and conditions for your records. All other electronic forms including HIPPA, Expectations for Care, Informed Consent and Electronic Data Authorization, examination and posture photo reports will be kept in your patient file and may be furnished upon written request. Research forms are not associated or stored with your patient information.
You authorize Mama’s Chiropractic Clinic to debit the bank account or credit card you provide for the amount of your Individual or Family plans on the reoccurring monthly schedule indicated. This amount will be used as a credit for your account against which your visits will be debited until you have exhausted the visit plan. This payment is for chiropractic and related health care services and you desire these services to maintain the health and fitness of your body.
You certify that you are an authorized user of the credit card or bank account you are using to pay for services at Mama’s Chiropractic Clinic, and that you will not dispute the payment with your Credit Card Company or Bank, so long as the transaction corresponds to the terms of this agreement.
You understand that returns, refunds and cancellations are not permitted, however exceptions may be made on a case-by-case basis and you agree to surrender a 6% charge-back fee. You understand that this authorization will remain in effect until the designated expiration date or until you cancel it in writing, whichever comes first, and you agree to notify Mama’s Chiropractic Clinic in writing of any changes in your account information or termination of this authorization at least 15 days prior to the next billing date. You agree to surrender a 6% transaction fee if you ask for return after the amount is charged to your account. Refunds may take 7-10 business days to return to your account. If the scheduled payment dates falls on a weekend or holiday, you understand that the payments may be executed on the next business day. For ACH debits to your checking/savings account, you understand that because these are electronic transactions, these funds may be withdrawn from your account as soon as your selected periodic transaction date.
In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) you understand that the business may at its discretion attempt to process the charge again within 30 days, and agree to an additional $35.00 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. You acknowledge that the origination of ACH transactions to your account must comply with the provisions of U.S. law.
Submitting to Insurance
You understand that on a quarterly basis you may request in writing your billing information so that you may submit it to your insurance company for re-imbursement. However, you understand that Mama’s Chiropractic Clinic, as a health care provider who does not belong to your insurance network, provides wellness care services which may not be covered by your insurance company. Therefore you understand that Mama’s Chiropractic Clinic is not responsible for the success or denial of your claim.
Eligibility for Individual, Pregnancy, and Additional Family Member Discount Programs
You understand that you must attend the Wellness Orientation Workshop offered within the first month of your care in order to be eligible for any of these discount programs. You will be given two opportunities to attend within that month, and failure to attend means you will be charged for chiropractic services at the per-visit rate starting on the day after the second missed workshop. You understand that discontinuing care by stopping payment or missing three consecutive scheduled appointments will end your eligibility for either program, at which time your balance may be refunded to you less the 6% transaction fee. You agree that if you choose to resume care you may be required to pay any required re-exam fees, at which point your eligibility will be restored. You affirm that your participation in both the Individual and Family programs are strictly voluntary, and agree that eligibility requirements and determinations are up to the discretion of Mama’s Chiropractic Clinic.
If you are seeking chiropractic care during your pregnancy, you understand chiropractic care during and after pregnancy is non-obstetrical in nature, and you chose these services for the health and fitness of your body. You understand that discontinuing care by stopping payment or missing three consecutive scheduled appointments will end your eligibility for either program.
You agree that only spouses or partners and/or dependent children qualify for Family Plans. You understand that if a family member loses their eligibility by missing three consecutive appointments or discontinuing care, this will not impact the other family members’ eligibility and they will be allowed to continue on the Family Plan. However, if that family member returns to care, you understand you may be required to pay any required re-exam fees, at which point your eligibility will be restored.
Examinations and adjustments outside of normal office hours are not included in your plan and must be paid for separately.
36 visit plans are only available to wellness care patients beginning in their second year of care at Mama’s Chiropractic Clinic or are transferring regular care from established chiropractic offices upon verification and approval. Families are eligible for 36 visit plans once all members have completed their first year of care.