New Patient Forms

Winters Wellness Center
New Patient Forms

Personal Information

Marital Status
In helping you solve problems and reach optimal health we work thru HIDN®. HIDN® involves Hormonal balance, Immune strength, Detoxification efficiency and Neurological connection. We are proud that HIDN® is unique enough to be awarded a US trademark. The next slides will have questions related to these topics.
Hormonal balance:
Immune strength :
Detoxification efficiency :
Neurological connection:
Please note: if you have any issues with mood, memory, anxiety, attention, concentration, or decision making, please print and complete our Brain Localization form on the New Patients page and bring it with you to your visit or email it to [email protected]. Also it is suggested you discuss with my staff how a " brain map " or qEEG can help us help you.
HIPAA Notification
Pursuant to HIPAA regulation, for any of our patients over the age of 18, we are unable to give any information, whether medical or financial, to any family member. This includes information about your spouse or your child, 18 years of age or older. Please read below and consider carefully who you want to have access to your medical/billing information.
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.
We will not leave messages with anyone except the patient or legal guardian. We will not leave any information on an answering machine. We will not leave messages on a voicemail unless we have your written permission to do so.
Patient’s Responsibilities Policy
1. If you have any updated information since your last visit (such as, change in name, address, phone number, or insurance) please notify the front desk staff when you arrive for your appointment.
2. Self-pay patients are required to make payment arrangements or pay in full on the day of your office visit.
3. If you have a previous balance on your account, you must pay this amount or make payment arrangements before 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.
5. Any appointments that are not cancelled before 24 hours of appointment time, will be billed to patient account at 50% of the service fee. If you miss an appointment and do not contact us prior to that appointment, you will be billed at 100% of the service fee.
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/INSURANCE uniform of assignment, release of information and financial disclosure
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.
RELEASE OF INFORMATION: I hereby authorize Winters Wellness Center to release information acquired during the course of my examination or treatment to my primary care doctor or to an appropriate insurance carrier. If Medicare patients, I further authorize release, of the Center of Medicare Services and its agents, any information needed to determine benefits payable for related charges.
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.
I, the undersigned, agree to all of the policies provided to me at this time.

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