CHIROPRACTIC WELLNESS MEMBERSHIP AGREEMENT
-Our bodies need constant attention to help different parts function at their best. Chiropractic is here to help keep your body functioning properly through your spine. Pain is NOT a proper guide to how well our bodies are functioning. Routine chiropractic treatment can help.
-This membership is designed to allow you to maintain proper and optimal function of your body through Chiropractic.Chiropractic is the detection and elimination of vertebral subluxation. Removing any interference to your nervous system through restrictions in your musculoskeletal system.
-You are being offered this membership because you have achieved a level of treatment deemed-MAINTENANCE. We are no longer treating an injury or specific symptom. The goal is to maintain your current level of function and hopefully a symptom free state of musculoskeletal health.
-IF YOU THINK YOU QUALIFY FOR THIS PLAN, PLEASE CALL US TODAY AND WE WILL GET YOU STARTED.
-The following agreement describes the terms of Chiropractic Wellness Membership and is constructed to allow electronic funds transfer from the below signed member and Sullivan Family Chiropractic for the purpose of a Chiropractic Wellness Membership Program retainer.
$120 (Individual) $240 (family**)
Summary of Terms and Benefits: This is a month to month contract that may be canceled at any time with 10 days written notice without penalty. Your plan will be discontinued at the end of your current paid plan month.
- This Chiropractic Wellness Membership Program is for the sole purpose of detection and correction of vertebral subluxation and is NOT for the diagnosis or treatment of any symptoms, diseases or conditions.
- NO therapies will be provided. If you want therapy (ie.ice, heat, electric stim or traction) $10/visit charge.
- NO xrays are included.
- If you have a new injury that requires further evaluation as determined by the doctor, you will be taken off of the program. Appropriate evaluation, examination and xrays may be warranted at the discretion of the doctor. At this time you may wish to file health insurance, auto accident claim, etc. Your membership program will be put on hold until returned to maintenance status.
- All memberships are based on monthly auto-debit by credit card, cash or check.
- All memberships are non-transferable.
- Fees charged are a retainer fee which allows access to the office during normal business hours.
- Members will receive a 100% discount on chiropractic adjustments during normal business hours.
- This agreement is not insurance. We assume no risk, monetary or otherwise.
- NO insurance will be filed for this service. You may NOT bill your insurance on your own for our services. Wellness Program membership is based on maintenance therapy. Insurance does NOT cover maintenance.
- No cash or credit refunds will be given for unused services. It is the Practice Member's sole responsibility to receive care per recommendations.
- We reserve the right to cancel membership at any time, for any reason.
- Membership Fee Guarantee: Price protection guarantee – price remains the same for a minimum of 12 months, as long as you are a member.
- *Unlimited Chiropractic visits are giving you availability for subluxation check and correction on an as needed basis during normal office hours.
- **family membership-includes all children in household + 2 parents
______________________________________ Credit Card Number_______ Type_______Expiration ____CVV
-I have read and I understand the above policies. I agree to the terms of Chiropractic Wellness Membership Program. Credit cards will be charged Monthly on membership date.
***Credit card information will be kept in locked file, in locked office.
DETAILS OF PATIENT AGREEMENT
This is an Agreement between Sullivan Family Chiropractic 2315 W Arbors Dr Suite 208A Charlotte, NC 28262, Michael D Sullivan DC (Chiropractor) in his capacity as an agent of Sullivan Family Chiropractic PA(SFC), and you, (Patient).
The Chiropractor, who specializes in chiropractic care, delivers care on behalf of NLC, at the address set forth
above. In exchange for certain fees paid by Patient, SFC through its chiropractic care, agrees to provide
Patient with the Services described in this Agreement on the terms and conditions set forth in this Agreement.
1. Patient. A patient is defined as those person or persons for whom the Chiropractor shall provide Services,
and who are signatories to, or listed on the documents attached as Appendix 1, and incorporated by reference,
to this agreement
2. Services. As used in this Agreement, the term Services shall mean a package of services, chiropractic and certain amenities (collectively “Services”), which are offered by SFC, and set forth in Appendix 1.
3. Terms. This agreement shall commence on the date signed by the party below and shall continue for a period
of one month, automatically renewed via credit card or bank information on file.
4. Fees. In exchange for the services described herein, Patient agrees to pay SFC, the amount as set forth in Appendix 1, attached. This fee is payable upon execution of this agreement, and is in payment for the services provided to Patient during the term of this Agreement. The agreement can be canceled at any time with 10 days written notice.
5. Non-Participation in Insurance. Patient acknowledges that neither SFC, nor the Chiropractor will file with any health insurance or plans, and provides wellness services that are NOT covered under Medicare guidelines. Neither of the above make any representations whatsoever that any fees paid under this Agreement are covered by your health insurance or other third party payment plans applicable to the Patient. The Patient shall retain full and complete responsibility for any such determination. If the Patient is eligible for Medicare, or during the term of this Agreement becomes eligible for Medicare, then Patient will sign the
Advanced Beneficiary Notice. This agreement acknowledges your understanding that the Chiropractor is providing wellness/maintenance services that are NOT covered by Medicare, and as a result, Medicare cannot be billed for any services performed for you by the Chiropractor. Patient agrees not to bill Medicare or attempt Medicare reimbursement for any such services. Patient shall renew and sign the Advanced Beneficiary Notice every year thereafter chiropractic care is provided.
6. Insurance or Other Medical Coverage. Patient acknowledges and understands that this Agreement is not
an insurance plan, and is not a substitute for health insurance or other health plan coverage (such as membership in an HMO). It will not cover hospital services, or any services not personally provided by SFC, or its Chiropractors. Patient acknowledges that SFC has advised that Patient obtain or keep in full force such health insurance policy(ies) or plan(s) that will cover Patient for general healthcare costs. Patient acknowledges that this Agreement is not a contract that provides health insurance, and this Agreement is not intended to replace any existing or future health insurance or health plan coverage that Patient may carry.
7. Work or Automobile Injury. If you are involved in a Work injury or Automobile injury and your care is covered under the respective policies, your Chiropractic Wellness Membership Program may be suspended without penalty and may be reinstated once care for those injuries has completed.
8. Term; Termination. This Agreement will commence on the date first written above and will extend monthly thereafter as long as payment is received. Notwithstanding the above, both Patient and SFC shall have the absolute and unconditional right to terminate the Agreement, without the showing of any cause for termination, upon giving 10 days’ prior written notice to the other party. The Agreement will automatically renew for successive monthly terms upon the payment of the monthly fee at the end of the contract month.
9. Communications. You acknowledge that communications with SFC/Chiropractor(s) using e-mail, facsimile, video chat, instant messaging, and cell phone are not guaranteed to be secure or confidential methods of communications. As such, you expressly waive SFC/Chiropractor’s obligation to guarantee confidentiality with respect to correspondence using such means of communication. You acknowledge that all such communications may become a part of your medical records. By providing Patient’s e-mail address, Patient authorizes SFC and its Chiropractors to communicate with Patient by e-mail regarding Patient’s “protected health information” (PHI) (as that term is defined in the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and its implementing regulations). Patient acknowledges that:
(a) E-mail is not necessarily a secure medium for sending or receiving PHI and there is always a possibility that a third party may gain access;
(b) Although and SFC/Chiropractor(s) will make all reasonable efforts to keep e-mail communications confidential and secure, neither SFC nor the Chiropractor(s) can assure or guarantee the absolute confidentiality of e-mail communications;
(c) At the discretion of SFC/Chiropractor(s), e-mail communications may be made a part of Patient’s permanent chiropractic record; and,
(d) Patient understands and agrees that e-mail is not an appropriate means of communication regarding emergency or other time-sensitive issues or for inquiries regarding sensitive information. In the event of an emergency, or a situation in which the patients could reasonably expect to develop into an emergency, Patient shall call 911 or the nearest emergency room, and follow the directions of emergency personnel. If Patient does not receive a response to an e-mail message within one day, Patient agrees to use another means of communication to contact SFC/Chiropractor(s). Neither SFC nor the Chiropractor(s) will be liable to Patient for any loss, cost, injury, or expense caused by, or resulting from, a delay in responding to Patient as a result of technical failures, including, but not limited to: (i) technical failures attributable to any internet service provider, (ii) power outages, failure of any electronic messaging software, or failure to properly address e-mail messages, (iii) failure of the Practice’s computers or computer
network, or faulty telephone or cable data transmission, (iv) any interception of e-mail communications by a third party; or (v) your failure to comply with the guidelines regarding use of e-mail communications set forth in this paragraph.
10. Change of Law. If there is a change of any law, regulation or rule, federal, state or local, which affects the Agreement including these Terms & Conditions, which are incorporated by reference in the Agreement, or the activities of either party under the Agreement, or any change in the judicial or administrative interpretation of any such law, regulation or rule, and either party reasonably believes in good faith that the change will have a substantial adverse effect on that party’s rights, obligations or operations associated with the Agreement, then that party may, upon written notice, require the other party to enter into good faith negotiations to renegotiate the terms of the Agreement including these Terms & Conditions. If the parties are unable to reach an agreement concerning the modification of the Agreement within (45) forty-five days after of date of the effective date of change, then either party may immediately terminate the Agreement by written notice to the other party.
11. Severability. If for any reason any provision of this Agreement shall be deemed, by a court of competent jurisdiction, to be legally invalid or unenforceable in any jurisdiction to which it applies, the validity of the remainder of the Agreement shall not be affected, and that provision shall be deemed modified to the minimum extent necessary to make that provision consistent with applicable law and in its modified form, and that provision shall then be enforceable.
12. Reimbursement for services rendered. If this Agreement is held to be invalid for any reason, and if SFC is therefore required to refund all or any portion of the monthly fees paid by Patient, Patient agrees to pay SFC an amount equal to the reasonable value of the Services actually rendered to Patient during the period of time for which the refunded fees were paid.
13. Amendment. No amendment of this Agreement shall be binding on a party unless it is made in writing and signed by all the parties. Notwithstanding the foregoing, SFC may unilaterally amend this Agreement to the extent required by federal, state, or local law or regulation (“Applicable Law”) by sending You 30 ( t h i r t y ) days advance written notice of any such change. Any such changes are incorporated by reference into this Agreement without the need for signature by the parties and are effective as of the date established by SFC, except that Patient shall initial any such change at SFCs request. Moreover, if Applicable Law requires this Agreement to contain provisions that are not expressly set forth in this Agreement, then, to the extent necessary, such provisions shall be incorporated by reference into this Agreement and shall be deemed a part of this Agreement as though they had been
expressly set forth in this Agreement.
14. Assignment. This Agreement, and any rights Patient may have under it, may not be assigned or transferred by Patient.
15. Relationship of Parties. Patient and the Chiropractor intend and agree that the Chiropractor, in performing his/her duties under this Agreement, is an independent contractor, as defined by the guidelines promulgated by the United States Internal Revenue Service and/or the United States Department of Labor, and the Chiropractor shall have exclusive control of his work and the manner in which it is performed.
16. Legal Significance. Patient acknowledges that this Agreement is a legal document and creates certain rights and responsibilities. Patient also acknowledges having had a reasonable time to seek legal advice regarding the Agreement and has either chosen not to do so or has done so and is satisfied with the terms and conditions of the Agreement.
17. Miscellaneous; This Agreement shall be construed without regard to any presumptions or rules requiring construction against the party causing the instrument to be drafted. Captions in this Agreement are used for convenience only and shall not limit, broaden, or qualify the text.
18. Entire Agreement: This Agreement contains the entire agreement between the parties and supersedes all prior oral and written understandings and agreements regarding the subject matter of this Agreement.
19. Jurisdiction: This Agreement shall be governed and construed under the laws of the State of North Carolina and all disputes arising out of this Agreement shall be settled in the court of proper venue and jurisdiction for SFC address in Charlotte, NC.
20. Service. All written notices are deemed served if sent to the address of the party written above or appearing in Exhibit A by first class U.S. mail.
The parties have signed duplicate counterparts of this Agreement on the date first written above.
Michael D Sullivan DC
Manager/Owner Sullivan Family Chiropractic PA, DBA Sullivan Family Chiropractic and Massage Therapy