Welcome to Whole Family Chiropractors. We are pleased you have chosen us for your health and wellness needs. At our clinic we treat you as an individual. Beyond treating specific injuries, we customize your therapy to meet broader health goals, striving to offer treatment that enhances your overall wellness.

Our practice began as a Chiropractic practice and has since expanded to include various physical medicine therapies including trigger point release and myo‐fascial and myo‐therapy as core services. Please understand that though you may find similarities between massage and this therapy, there is a significant difference. Our therapists are specially trained and directed by Dr. Paris on your specific case with targeted goals in mind. Again, this is not massage therapy but rather part of your chiropractic coordination of care designed to speed the healing process and lead to stability. 

Our staff works to make your experiences at our office pleasant, efficient and beneficial. Since we schedule to be ready for you at your specific time, we ask that you please be on time for your appointment. A routine office visit is 15 minutes in length. We understand that some circumstances require more time; for example, a new injury or extreme pain. If you think you may require a longer appointment, please ask the office staff to schedule accordingly. Occasionally, we need to treat an emergency that takes longer than we have
anticipated. If we are running behind, we ask for your patience and understanding. If you have a serious time‐crunch, please let us know and we will try to accommodate your schedule. 

Our holistic approach to healthcare includes awareness that, in some cases, you may need a specialty that we do not offer. We can refer you to physicians with a like-minded commitment to consider you as the whole person you are. In some cases, to facilitate your recovery or optimal health, we may determine that co-management of your cases is the best choice. It is also not uncommon for us to seek a second opinion.  We are committed to insuring you the most efficacious treatment and if there is a specialist that may be able to provide additional insight for us, we will ask for a consult. Additionally, the doctor may recommend a specific diagnostic or screening tests; it is your responsibility to schedule them and / or follow up with your PCP. I.e. abnormal blood pressure.

We know you have a choice in health care, and we are committed to exceeding your expectations. Please let us know if there is anything we can do to make you visits with us more comfortable. 

If you are unable to keep your scheduled appointment, please let us know as soon as possible so we may schedule another person who needs our services into that time slot. Since we may have a waiting list, a late cancellation means someone else missed out on an appointment. We also want to help you keep your treatment plan active and effective. We will always make time to see you even if you are late, you just may need to wait a short time. There is a 24‐hour cancellation policy for myo‐therapy appointments. Less than 24 hours will be charged a $85 late‐cancellation fee. If you are late for your therapy appointment you will be charged for the full time you have scheduled. A missed therapy appointment will be charged $85.

We request payment at the time of services rendered. A 1.5% interest will accrue and be assessed monthly to accounts 30 days past due. Accounts are delinquent at 45 days and are subject to a continuing compounded interest each month or collections. Whole Family Chiropractors reserves the right to charge reasonable collections for attorney’s fees to all delinquent accounts. Financial arrangements are subject to renewal at the start of each new year. Should changes arise in your medical or financial situation that would affect your current financial agreement, you must notify our office prior to your next appointment. Should you discontinue care or be released from further service at our office, all outstanding balances will be due. Our office accepts cash, checks, and all major credit cards. Exceptions to this policy are detailed below. If you have a genuine financial hardship, please let us know and we will consider reducing fees or offering a payment plan to assist with the hardship.

If you have an outstanding balance after 2 weeks, and not have scheduled another appointment or made prior arrangements with our staff, you authorize Whole Family Chiropractors to charge the credit card previous given for any and all remaining balances. 

This office is currently in network with Medicare, BCBSTX, Oscar, Humana, Aetna and Seton Health Care. In many cases, as a courtesy to you, we will bill your insurance company. To do this, we will require an assignment of benefits to allow us to be paid directly by your insurance company. Our contract with these insurers mandates that from the patient we collect plan deductibles, copays and/or coinsurance as per the individual policy and this office agrees to electronically submit charges for all services performed.

For all other insurance policies, we charge our regular fees, and as a courtesy, will submit bills to the insurance company for consideration. If the policy does offer out‐of-network chiropractic benefits, and the deductible is $1500 or less, we will submit bills to the insurance company. We will also agree to collect the policy deductible, copay and/or co‐insurance and all payments will be applied to the account accordingly.

In the event there is no coverage, insufficient coverage, or a deductible that exceeds $1500, we may make a 'prompt pay discount' or ‘pre‐payment discount’ available consistent with our private pay patients. You may elect to have us not bill your insurance company, even if we are in network, by selecting this option on the payment form.

Our office accepts insurance assignment under special conditions. After insurance coverage has been verified, we will submit claim forms directly to your insurance company and collect your patient co‐payment and deductible, if applicable. However, please understand that this is a courtesy to you, and that you are fully responsible for any amount not paid by your insurance. The contract for health insurance is of course between you and your insurance company.

Carefully review your “Explanation of Benefits” when you receive it in the mail. Call your insurance carrier directly to resolve any discrepancies on your claims to avoid out of pocket expenses. We will make every attempt to facilitate the processing of claim forms. Verification of benefits by our office does not guarantee that the insurance company will pay your claim. We will not enter into a dispute with your insurance company over your claim; however, we may ask you to consider filing a dispute on our behalf.

In the event that your insurance company or attorney inadvertently sends payments to you for services we have performed, any checks should be endorsed and sent to Whole Family Chiropractors with the Explanation of Benefits that normally accompanies the check.

If you have sustained an injury on the job, and it is determined to have occurred during work related to your employment, we will refer you to a doctor that accepts Worker's Compensation cases.

If you have sustained a non‐work related personal injury it is our office policy regarding motor vehicle crashes (regardless of fault) that we will bill the appropriate PIP/MedPay policies, followed by 3rd party, and only as a last resort, at the end of treatment will we decide whether to agree to bill health insurance. Regarding 3rd party claims, patients who are not legally represented will pay a minimum of $25 per regular office visit toward total fees and $85 toward any manual therapy fees. Please be aware that we do not discount our bill
at the end of treatment for any reason.

By signing this office policy document, you agree to receive unencrypted email or text messages regarding missed appointments or other office reminders.

As part of our HIPAA policy, please understand that any information conveyed to the doctors will be shared between them and any within the referring provider group, but not between you and the therapist as they information provided to the therapists is confidential are working under the delegation of the doctors.

Returned checks will be assessed a $20.00 fee. An interest rate of 1.5% monthly may be applied to any unpaid balances. In signing below, I understand these policies and agree to pay for treatment accordingly, and also agree that I am responsible for any unpaid balances. I further understand that with regard to personal injury legal cases, any monies due to Whole Family Chiropractors must be paid no later than 15 days following the date of settlement. Withholding payment or defaulting on a medical debt is considered a legal breech of this contract.

I understand that Whole Family Chiropractors may report me to a credit‐reporting agency or take legal action as necessary to be paid for services rendered. Whole Family Chiropractors reserves the right to charge reasonable collections for attorney’s fees and/or collection agency fees to all delinquent accounts. Should a credit remain on an account once a patient discontinues treatment for any reason, a full audit will occur, and any balance resolved within 45 days.

We offer hardship discounts for significant financial hardship on a case by case basis; we hope you will respect this offering and let us know if your financial outlook improves to allow the offer can be extended to another person. (Completed financial form required)

If your doctor has suggested a treatment plan that you have agreed to that has a prepayment discount and you do not complete or comply with the plan, any monies paid in advance will be returned to you on a pro‐rated basis.

We genuinely wish to provide you with the best service and treatment that we can. Please do not hesitate to let us know how we can better serve you. We genuinely care about each of our patients, care about the experience they have in our office and are honored and humbled each time someone entrusts us with their healthcare.

Our office will make every attempt to verify your policy benefits, however, this office and your insurance DOES NOT guarantee a quote of benefits for payment of services provided. Your insurance should pay within 35 days from the date in which it was filed. In the event that your insurance company does not pay in a timely manner, you may be asked to contact your insurance carrier.

I, the undersigned patient/parent, grants and conveys to Whole Family Chiropractors LLC, a lien against the proceeds of the patient’s insurance settlement with all the following rights, power and authority. 

Whole Family Chiropractors LLC, and payment to be sent to 4818 Berkman Dr, Suite 100, Austin, TX 78723 This demand specifically conforms to Article 21.55 of the Texas Insurance Code, providing for attorney fees, 18% penalty, court cost, and interest from judgment, upon violation.

In the event my insurance settlement proceeds are paid directly to my attorney, I hereby irrevocably instruct my attorney to withhold all such sums and amounts as are determined to be owed, due and payable on my account and remit payment of all such sums directly to the above named doctor and/or treating facility upon receipt of my settlement award(s).

I hereby assign the exclusive, irrevocable right to any cause of action that exists in my favor against any insurance company for the terms of the policy, including the exclusive, irrevocable right to receive payment for such services, make demand for payment, and prosecute and receive penalties, interest, court loss, or other legally compensable amounts owed by an insurance company in accordance with Article 21.55 of the Texas Insurance Code to cooperate, provide information as needed, and appear as needed to assist in the prosecution of such claims for benefits upon request.

To any insurance company providing benefits or settlement of a claim, you are instructed to pay the total dollar amount of all sums which I owe on account to the above named doctor and treating facility within 30 days following your receipt of such bills for services to the extent that such bills are payable under the terms of the policy. If my injuries are the result of negligence from a third party, then I instruct the Liability carrier to cut a separate check to pay in full all services rendered by this office.

I hereby grant the above‐named facility/physician the power to endorse my name upon any checks, drafts, or other negotiable instrument representing payment from any insurance company for treatment rendered by this office. I agree that any payment in excess of the charges for treatment rendered will be credited to my account or forwarded to my address.

I hereby authorize the above facility/physician to establish a PIP or UM claim on my behalf. I also instruct my insurance carrier to provide upon request of the provider, any rejections in writing as they apply to my lack of PIP or UM/UIM coverage. If my carrier is unable to provide said rejections in a timely manner, I acknowledge that I am entitled to minimum levels of coverage, as per section 1952.152 of the Texas Insurance Code, and further instruct my carrier to pay up to available limits directly to the facility named above.

If your insurance company mails a check directly to you for our services, you must bring the misdirected check to our office within 48 hours.

You are the decision maker for your health care. Part of our role is to provide you with information to assist you in making informed choices. This process is often referred to as “informed consent” and involves your understanding and agreement regarding the care we recommend, the benefits and risks associated with the care, alternatives, and the potential effect on your health if you choose
not to receive the care.

We may conduct some diagnostic or examination procedures if indicated. Any examinations or tests conducted will be carefully performed but may be uncomfortable.

Chiropractic care centrally involves what is known as a chiropractic adjustment. There may be additional supportive procedures or recommendations as well. When providing an adjustment, we use our hands or an instrument to reposition anatomical structures, such as vertebrae. Potential benefits of an adjustment include restoring normal joint motion, reducing swelling and inflammation in a joint, reducing pain in the joint, and improving neurological functioning and overall well‐being.

It is important that you understand, as with all health care approaches, results are not guaranteed, and there is no promise to cure. As with all types of health care interventions, there are some risks to care, including, but not limited to: muscle spasms, aggravating and/or temporary increase in symptoms, lack of improvement of symptoms, burns and/or scarring from electrical stimulation and from hot or cold therapies, including but not limited to hot packs and ice, fractures (broken bones), disc injuries, strokes, dislocations,
strains, and sprains. With respect to strokes, there is a rare but serious condition known as a cervical arterial dissection that involves an abnormal change in the wall of an artery that may cause the development of a thrombus (clot) with the potential to lead to a stroke. This occurs in 3‐4 of every 100,000 people whether they are receiving health care or not. Patients who experience this condition often, but not always, present to their medical doctor or chiropractor with neck pain and headache. Unfortunately, a percentage of these patients will experience a stroke. As chiropractic can involve manually and/or mechanically adjusting the cervical spine, it has been reported that chiropractic care may be a risk for developing this type of stroke. The association with stroke is exceedingly rare and it is estimated to be related to in one in one million to one in two million cervical adjustments.

It is also important that you understand there are treatment options available for your condition other than chiropractic procedures. Likely, you have tried many of these approaches already. These options may include, but are not limited to: self‐administered care, over‐the‐counter pain relievers, physical measures and rest, medical care with prescription drugs, physical therapy, bracing, injections, and surgery. Lastly, you have the right to a second opinion and to secure other opinions about your circumstances and health care as you see fit.

I have read, or have had read to me, the above consent. I appreciate that it is not possible to consider every possible complication to care. I have also had an opportunity to ask questions about its content, and by signing below, I agree with the current or future recommendation to receive chiropractic care as is deemed appropriate for my circumstance. I intend this consent to cover the entire course of care from all providers in this office for my present condition and for any future condition(s) for which I seek chiropractic care from this office.

I have read and agree to the office policies and the 4 pages of this document.