Hormonal balance:

Immune strength :

Detoxification efficiency :

Neurological connection:

HIPAA Notification

I give Winters Wellness Center permission to leave phone messages regarding my medical care and/or lab results at the following numbers. My medical care/billing account may be discussed with the person(s) listed below.

Patient’s Responsibilities Policy

2. Self-pay patients are required to make payment arrangements or pay in full on the day of your office visit.

4. You agree, in order for us to serve your account, notify you of information pertaining to your account, or for the purposes of collection, that we may contact you by telephone at any number provided by you including wireless telephone numbers. Methods of contact may include the use of pre-recorded and artificial voice messages, text messaging and/or use of an automated dialing service.

6. Medicare is the only insurance company Dr. Winters is in network with and Medicare only pays on acute spinal care. For non Medicare patients no insurance is filed or reports written. However, Health Savings Accounts can be used for payment. The only services which are eligible for a super bill to file yourself are exams and standard chiropractic adjustments that do not fall under the maintenance definition from Medicare and which applies to all insurance companies. That definition is : “Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy.” (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3A)

Notice of Privacy Practices

I have read, understand, and agree to the Notice of Privacy Practices for protected health information that was provided to me by Winters Wellness Center.

MEDICARE ASSIGNMENT OF BENEFITS: I hereby assign or transfer payment benefits made to me and my behalf to Winters Wellness Center for any services furnished to me by this facility. I further agree that I am responsible for payment or charges incurred by me that are not covered by my insurance or for which my insurance has paid me.

PERMISSION TO CONTACT: I hereby authorize Winters Wellness Center to use the provided contact information to send me personal messages and messages intended for all patients, current and previous to the practice, including - but not limited to - upcoming event announcements, practice closure alerts, and other information.