Evolve Chiropractic Membership Policies

1. Membership Coverage:

• The Personal Evolution Membership at Evolve Chiropractic includes access to the following services:
  • Regular NetworkSpinal care sessions as outlined in the chosen membership plan.
  • Access to intensive healing weekends held quarterly.
  • Two 30-minute consultations per annual plan.
  • 50% savings on additional consultations and wellness evaluations as needed.
  • Other intuitive energy healing modalities provided by Evolve Chiropractic.

2. Cancellation Policy:

• Both members and Evolve Chiropractic reserve the right to cancel the membership at any time.
• Members may cancel their membership by providing written notice to Evolve Chiropractic.
• Evolve Chiropractic may cancel a membership if the member violates the terms and conditions of the membership agreement or fails to adhere to practice policies.
• In the event of cancellation, any unused portion of the membership fee will be refunded to the member on a prorated basis.

3. Sessions Do Not Carry Over:

• Unused sessions or benefits do not carry over to the following month.
• Members are encouraged to utilize their allocated sessions within the billing cycle to maximize the benefits of their membership.

4. Refunds and Flexibility:

• Evolve Chiropractic understands that circumstances may arise that prevent members from utilizing their membership benefits.
• In extenuating circumstances, such as illness, injury, or other unforeseen events, Evolve Chiropractic may offer refunds or accommodations on a case-by-case basis.
• Members are encouraged to contact Evolve Chiropractic directly to discuss any issues or concerns regarding their membership.

5. Exclusions:

• The Personal Evolution Membership does not include any conventional chiropractic services regulated by the state.
• Conventional chiropractic services are available separately and may be subject to different billing and pricing structures.

6. Notice of Updates:

• Evolve Chiropractic will provide notice to all currently subscribed members via email of any pending changes to the membership policies.
• Members are encouraged to review these updates and reach out with any questions or concerns.

7. Integrity and Fairness:

• If any unforeseen circumstances have not been outlined in this policy, Evolve Chiropractic always strives to practice with integrity and aims to be as fair as possible in all situations.

8. Agreement Acknowledgment:

By enrolling in the Personal Evolution Membership, members acknowledge that they have read, understood, and agreed to adhere to the practice policies outlined above.
Evolve Chiropractic reserves the right to update or modify these policies as needed, with prior notice to members.

Financial Policy

Paying for Your Care

• We provide full disclosure of all costs associated with your care.
• You will not be charged for any services without your acknowledgement of your financial responsibility for the services provided.
• We do not accept insurance payments of any kind.
  • There are no billing codes established for NetworkSpinal Care. This care is not a specific treatment for a diagnosed condition and is unlikely to be covered by health insurance plans. If you would like to contact your insurance carrier and ask if they will provide coverage for NetworkSpinal billed with the “97139 – unlisted therapy code” we will be glad to provide you with a superbill and a document we have prepared to explain the care procedures and the use of the unlisted therapy code.
• You are responsible for paying for the services provided and products purchased at Evolve Chiropractic at time of service or before services are provided with monthly or full plan prepayments.
• You can keep a card on file in your patient portal through our secure transaction processor (Square) so your payments can be processed automatically. Card receipts are provided through our patient portal. Printed receipts are available on request.
  • You may also make payments using cash, checks, or any other type of transactions accepted by Square.
• All services are non-refundable once provided.
• Full refunds are available upon request for any prepaid services that have not been provided.
  • Care and payment plan agreements are not binding contracts and may be cancelled at any time. If you decide to cancel your care plan, you are welcome to return for a re-evaluation and new care plan at any time.
• We accept payments from CareCredit for up to 3 months of care at a time. (Details below)

Cost of Care

The individual service rates are provided below for your reference.

• Initial Visit with Complete Spinal Wellness Evaluations: $150-$250 (higher cost exams when extra time is needed for reviewing medical records or imaging)
  • Includes full spinal thermal and muscle (sEMG) scans and heart rate variability (HRV) scans, posture evaluation, dual scale weight distribution, motion and static palpation of your spine, muscles, and extremities (arms, legs, TMJ, if indicated).
  • Manual muscle, sensory, and reflex testing, when indicated.
  • Spinal wellness evaluations are not intended to diagnose and manage conditions. Instead, the focus is on evaluating your spinal-neural integrity, wellness, and overall adaptability.
• Monthly Progress Evaluations: $75
• NetworkSpinal Care Appointment: $60
  • Also known as “NetworkSpinal Entrainments” or “NetworkSpinal Adjustments.”
• Additional Consultations: $50 each 15 minutes

Other Services
The primary service provided at Evolve Chiropractic is NetworkSpinal Care. There may be times when you need other forms of care or rehabilitation. Your needs will be assessed through an exam with Dr. Jason, and you may be referred to an appropriate care provider for other needs you have.

If Dr. Jason provides other services, they are only provided for practice members currently receiving NetworkSpinal Care.

• Chiropractic adjustment of 1-2 areas of the spine: $60; 3-4 areas: $75
• Chiropractic adjustment of extremities: $30
• Manual muscle testing and muscle therapies: $100/20 minutes

If NetworkSpinal Care is provided in combination with other chiropractic adjustments, the fee for NetworkSpinal is reduced by $40 due to overlap in the exam component of the combined services.

Special Rates

• Household Family Members
  • Your children ages 0-17 may receive NetworkSpinal Care with a 30% savings on their care while you are also receiving care.
• Personal Evolution Membership
  
  • For practice members who choose to make NetworkSpinal care and other energy balancing services available at Evolve a part of their lifestyle, we offer significant savings on care and special member events in the form of an annual membership. See next section for details about our membership policies.

• Special Considerations
  • We reserve the right to support those in need and offer hardship and/or charitable rates on an individual basis. Within this consideration we reserve the right to limit how many people we serve with hardship/charitable rates and/or to designate select services as eligible for these rates to ensure the financial health of our practice and maintain our ability to continue service to others.

CareCredit Financing Options

• You can use your CareCredit card as a standard time of service payment method with your standard card financing rates.
• For transactions over $200, you may choose to use a 6-month financing plan and for transactions over $400, you may choose to use a 12-month financing plan where you will not be charged any interest if you take care of the monthly payments on time and pay the entire balance before the end of the term. If you are unable to take care of the entire amount prior to the end of your financing term, 26.9% APR is applied to the entire transaction amount.
• Only 90-days’ worth of services can be applied at a time to a CareCredit card, so you cannot use your CareCredit card for one-time payment of care plans lasting longer than 90 days.
• Evolve Chiropractic is charged a financing fee for use of CareCredit, so we do not offer additional savings for prepaid or monthly care plan payments when using CareCredit.
• To learn more about CareCredit, see the brochure in our office or visit: (https://www.carecredit.com/go/484DGM/) to learn more online.

Informed Consent for Care at Evolve Chiropractic

We encourage and support a shared decision-making process between us regarding your health needs. As a part of that process you have a right to be informed about the condition of your health and the recommended care to be provided to you so that you can make the decision whether to undergo such care with full knowledge of the known risks and intended benefits. This information is intended to make you better informed so you can knowledgably give or withhold your consent.

At Evolve Chiropractic, we provide a specific form of spinal care known as NetworkSpinal ®.  NetworkSpinal Care is an evidence-based approach to wellness and body awareness.  This approach is only taught to chiropractors and includes a unique application in spinal care.

Many practice members who have been under NetworkSpinal Care in our office have reported significant changes in their lives.  Many have reported strong emotional experiences that have been associated with discovering and releasing long standing stress and tension in their bodies and lives.  There is no guarantee that you will have these experiences though it is not recommended that you begin this form of care if you are not open to experiencing your body in a new way and improving your lifestyle.

 Acknowledgements

I hereby request and consent to receiving spinal care, including wellness education in this office by Jason Dixon, DC, who provides NetworkSpinal (NS) Care, a low force approach which has unique outcomes and clinical results. Dr. Jason chooses to practice NS, as he is professionally and personally confident regarding the safety and effectiveness of this form of care. 

This office provides care in accordance with the Council on Chiropractic Practice Guidelines and the Canon of Ethics of the Association for NetworkSpinal Care. Dr. Jason has been trained in traditional chiropractic care and is continuously training in the latest procedures of NetworkSpinal Care. 

The purpose of this consent form is to help me better understand the nature of the services offered in this office and our mutual responsibilities. This fosters a more effective relationship and avoids misunderstandings regarding expectations. Having well understood expectations is anticipated to promote a greater sense of safety and healing. 

NS Care does not attempt to manually, or by instrument, manipulate spinal fixations structurally (often associated with a snapping or popping sound), nor does it directly treat painful areas of the spine and body. Instead, by enhancing my body’s awareness of itself and specifically my spine, I understand I can develop new strategies for healing, adapting to stress, and experiencing wellness. These strategies promote spontaneous self-correction and self-regulation of spinal tension patterns and supports my natural ability to heal. 

NS Care consists of gentle touch contacts along the neck and back to achieve greater communication between the brain and body, and new sensory and motor strategies. NS Care adopts an approach associated with somatic (body/spinal awareness) training. There is a body of research characterizing NS Care and documenting its unique and significant wellness benefits. I understand I may obtain copies of published research articles and/or abstracts in this office. I can learn more about this process of care at https://www.fortworthevolve.com/networkspinalcare. I can also learn more about NetworkSpinal care from the developer of the care at https://epienergetics.com/welcome-networkspinal

I am aware that I will be receiving gentle touch NetworkSpinal adjustments, also called Entrainments. Assessments of my progress will include monitoring of my spine and body awareness, responsiveness to inner rhythms, tension, and ease patterns. At regular intervals, following commencement of care, reassessments will be performed. These will include my personal perception of my wellness and my awareness of my spine and body-mind changes. Dr. Jason will report to me the improvement in my spinal and nervous system integrity and my ability to self-regulate tension and to re-organize my spine through his observations and objective instrumentation.

NS Care is advanced through a series of levels of care. Each Level of Care involves the development of new and unique spontaneous spinal wave motions, other body movements, and oscillations. These waves, which are suggested to be associated with the greater spinal stability, the redistribution of energy, and the transfer of internal information are also associated with greater wellness, improved quality of life, and increased life enjoyment. 

I also understand that, in addition to NS Care and wellness education, Dr. Jason may perform additional examinations or assessments and offer health/spinal care or advice that is consistent with my individual needs. 

It has been explained to my satisfaction, and I understand that the care offered at Evolve Chiropractic is not a form of, or replacement for, the diagnosis or treatment of any symptom, disease, or malady. Instead, it is a form of wellness care and self-education that empowers my connection with my body-mind and develops new strategies for spinal and nervous system integrity and wellness. It develops new capacities in my body for the identification of, spontaneous release of, and redirection of tension, including those that are unique to NS Care. 

It is common for people receiving NS Care to breathe more deeply and more fully, engaging the spine with their respiration, to spontaneously adapt postures that release or redistribute tension, to bust stress, and to experience more of their inner life energy. 

I understand it is common to experience a wider range of motion and emotion during care. It is common, as care progresses, to find new options in the body and in life, which often lead to significant life changes.  

This form of care is NOT suggested for those individuals who wish to remove a symptom or condition without the occurrence of other fundamental changes in their lives. The care at Evolve Chiropractic often promotes significant changes in health choices, lifestyle, experience of the body-mind, emotion, and consciousness. 

Rather than attempting to simply return me to my previous state minus a symptom, Dr. Jason instead chooses to help me achieve new levels of wellness and life potential that I may never have had before. 

NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Our Legal Duty

We are required by law to maintain the privacy of protected health information and to provide you with notice of our legal duties and privacy practices with respect to your protected health information.  We must abide by the terms of this Notice while it is in effect.  However, we reserve the right to change the terms of this Notice and to make the new notice provisions effective for all the protected health information that we maintain.  If we make a change in the terms of this Notice, we will notify you in writing and provide you with a paper copy of the new Notice, upon request.

Uses and Disclosures

There are a number of situations in which we may use or disclose to other people or entities your confidential health information.  Certain uses and disclosures will require you to sign an acknowledgement that you received this Notice of Privacy Practices.  These include treatment, payment, and health care operations.  Any use or disclosure of your protected health information required for anything other than treatment, payment or health care operations requires you to sign an Authorization.  Certain disclosures that are required by law, or under emergency circumstances, may be made without your Acknowledgement or Authorization.  Under any circumstance, we will use or disclose only the minimum amount of information necessary from your medical records to accomplish the intended purpose of the disclosure.

We will attempt in good faith to obtain your signed Acknowledgement that you received this Notice to use and disclose your confidential medical information for the following purposes.  These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office once you have provided Consent.

Treatment.  Example: We may use your health information within our office to provide health care services to you or we may disclose your health information to another provider if it is necessary to refer you to them for services. 

Payment.  Example: We may disclose your health information to a third party such as an insurance carrier, an HMO, a PPO, or your employer, to obtain payment for services provided to you.

Health Care Operations.  Example: We may use your health information to conduct internal quality assessment and improvement activities and for business management and general administrative activities.

Appointment Reminders.  Example: Your name, address and phone number and health care records may be used to contact you regarding appointment reminders (such as voicemail messages, postcards, or letters), information about alternatives to your present care, or other health related information that may be of interest to you.

In the following cases we never share your information unless you give us written permission: Marketing purposes, sale of your information, most sharing of psychotherapy notes. In the case of fundraising:  We may contact you for fundraising efforts, but you can tell us not to contact you again.

There are certain circumstances under which we may use or disclose your health information without first obtaining your Acknowledgement or Authorization:

Those circumstances generally involve public health and oversight activities, law-enforcement activities, judicial and administrative proceedings, and in the event of death.  Specifically, we may be required to report to certain agencies information concerning certain communicable diseases, sexually transmitted diseases, or HIV/AIDS status.  We may also be required to report instances of suspected or documented abuse, neglect, or domestic violence.  We are required to report to appropriate agencies and law-enforcement officials information that you or another person is in immediate threat of danger to health or safety as a result of violent activity.  We must also provide health information when ordered by a court of law to do so.  We may contact you from time to time to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.  You should be aware that we utilize an “open adjusting room” in which several people may be adjusted at the same time and in proximity.  We will try to speak quietly to you in a manner reasonably calculated to avoid disclosing your health information to others; however, complete privacy may not be possible in this setting.  If you would prefer to be adjusted in a private room, please let us know and we will do our best to accommodate your wishes.

Others Involved in Your Healthcare:  Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care.  If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.  We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition, or death.  Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your healthcare.

Communication Barriers and Emergencies:  We may use and disclose your protected health information if we attempt to obtain consent from you but are unable to do so because of substantial communication barriers and we determine, using professional judgment, that you intend to consent to use or disclosure under the circumstances.  We may use or disclose your protected health information in an emergency treatment situation.  If this happens, we will try to obtain your consent as soon as reasonably practicable after the delivery of treatment.  If we are required by law or as a matter of necessity to treat you, and we have attempted to obtain your consent but have been unable to obtain your consent, we may still use or disclose your protected health information to treat you.

EXCEPT AS INDICATED ABOVE, YOUR HEALTH INFORMATION WILL NOT BE USED OR DISCLOSED TO ANY OTHER PERSON OR ENTITY WITHOUT YOUR SPECIFIC AUTHORIZATION, WHICH MAY BE REVOKED AT ANY TIME.  Except to the extent disclosure has been made to governmental entities required by law to maintain the confidentiality of the information, information will not be further disclosed to any other person or entity with respect to information concerning mental-health treatment, drug and alcohol abuse, HIV/AIDS or sexually transmitted diseases that may be contained in your health records.  We likewise will not disclose your health-record information to an employer for purposes of making employment decisions, to a liability insurer or attorney as a result of injuries sustained in an automobile accident, or to educational authorities, without your written authorization.

Patient Rights

Right to Request Restrictions.  You may request that we restrict the uses and disclosures of your health record information for treatment, payment and operations, or restrictions involving your care or payment related to that care.  We are not required to agree to the restriction; however, if we agree, we will comply with it, except with regard to emergencies, disclosure of the information to you, or if we are otherwise required by law to make a full disclosure without restriction. Your request must be made in writing to our Privacy Official. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Right to Receive Confidential Communications.  You have a right to request receipt of confidential communications of your medical information by an alternative means or at an alternative location.  If you require such an accommodation, you may be charged a fee for the accommodation and will be required to specify the alternative address or method of contact and how payment will be handled. Your request to receive confidential communications must be made in writing to our Privacy Official.

Right to Inspect and/or Copy.  You have the right to inspect, copy and request amendments to your health records including electronic health records.  Access to your health records will not include psychotherapy notes contained in them, or information compiled in anticipation of or for use in a civil, criminal, or administrative action or proceeding to which your access is restricted by law.  We will charge a reasonable fee for providing a copy of your health records, or a summary of those records, at your request, which includes the cost of copying, postage, and preparation or an explanation or summary of the information.  Your request to inspect and/or copy your health information must be made in writing to our Privacy Official.

Right to Amend.  You have the right to request that we amend certain health information for as long as that information remains in your record. Your request to amend your health information must be made in writing to our Privacy Official and you must provide a reason to support the requested amendment.

Right to Receive an Accounting.  You have the right to inspect, copy and request amendments to your health records.  Access to your health records will not include psychotherapy notes contained in them, or information compiled in anticipation of or for use in a civil, criminal, or administrative action or proceeding to which your access is restricted by law.  We will charge a reasonable fee for providing a copy of your health records, or a summary of those records, at your request, which includes the cost of copying, postage, and preparation or an explanation or summary of the information.  Your request to receive an accounting must be made in writing to our Privacy Official. 

Right to Receive Notice.  You have the right to receive a paper copy of this Notice, upon request. We are obligated to notify you if there is a breach of your PHI unless there is a low probability of PHI compromise.

Complaints

You may file a written complaint to us or to the Secretary of Health and Human Services if you believe that your privacy rights with respect to confidential information in your health records have been violated.  All complaints must be in writing and must be addressed to the Privacy Officer (in the case of complaints to us) or to the person designated by the U.S. Department of Health and Human Services if we cannot resolve your concerns.  You will not be retaliated against for filing such a complaint.

All questions concerning this Notice or requests made pursuant to it should be addressed to: Privacy Officer, Evolve Chiropractic, 5801 Curzon Ave, Ste 213, Fort Worth, TX 76107.   Effective date of this notice: 05/09/2023

CARD PAYMENT POLICY for SERVICES & PRODUCTS

Payments for all services provided and products purchased at Evolve Chiropractic (EC) are due at the time services are provided and products are given to you. We do not ship products sold in our office.

When using a debit or credit card to make your payments:

-We accept all major credit cards using Square

-You may pay for services at the time they are rendered by using our self checkout kiosk or allowing us to keep your card on file in our secure patient portal (processed through Square).

-No credit card information is ever kept on physical or digital media at EC or on any of EC’s servers.

We also accept cash or personal checks. ($35 fee is charged for any checks that are returned as NSF)

PRIVACY POLICY

We respect and are committed to protecting your privacy. We may collect personally identifiable information when you visit our site. We also automatically receive and record information on our server logs from your browser including your IP address, cookie information and the page(s) you visited. We will not sell your personally identifiable information to anyone.

SECURITY POLICY

Your payment and personal information is always safe. Our Secure Sockets Layer (SSL) software is the industry standard and among the best software available today for secure commerce transactions. It encrypts your personal information so that it cannot be read over the internet.

REFUND POLICY

Prepayment for services at Evolve Chiropractic simplifies your experience in our office, and may qualify you for discounts on services. Any payments you make to our office for services in advance to the receipt of those services are applied as a credit to your account with EC. All account credit is held in escrow until services are rendered.

In the event of a need to cancel/discontinue a course of care that you have prepaid for: any refunds for services which have not been rendered will be provided as a credit to the credit card used at the time of purchase within seven (7) business days of the request. If refunds to the card cannot be made, we will issue a refund with a check. There are no penalties which would reverse care plan special pricing when a refund is requested, though cancellation of a discounted care plan will prevent eligibility for future plan discounts.