Good Faith Estimate
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost
Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
• Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item, if possible. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
• Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.
Notice of Privacy Practices
Your Information. Your Rights. Our Responsibilities.
This document describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Any questions regarding this Notice should be directed to Caledonia Chiropractic Clinic's Privacy Officer, Julie Schneider, who can be reached at 262-681-8829 or [email protected]
Your Rights
You have the right to:
Get a copy of your paper or electronic medical record
Correct your paper or electronic medical record
Request confidential communication
Ask us to limit the information we share
Get a list of those with whom we’ve shared your information
Get a copy of this privacy notice
Choose someone to act for you
File a complaint if you believe your privacy rights have been violated
Your Choices:
You have choices in the way that we use and share information as we:
Tell family and friends about your condition
Provide disaster relief
Market our services and sell your information
Our Uses and Disclosures:
We may use and share your information as we:
Treat you
Run our organization
Bill for your services
Help with public health and safety issues
Do research
Comply with the law
Work with a medical examiner or funeral director
Address workers’ compensation, law enforcement, and other government requests
Respond to lawsuits and legal actions
Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get a copy of your medical record.
You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record.
You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications.
You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
We will say “yes” to all reasonable requests.
Ask us to limit what we use or share.
You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
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.
Get a list of those with whom we've shared information
You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
We will not retaliate against you for filing a complaint.
Attention Medicare and Medicare Replacement Patients
Exams and reexams are not covered by Medicare but may be covered by Medicare supplements and replacement policies. We have no way of knowing this for sure in advance. We will submit claims for these exams or reexams to your insurance, but please be aware that you may be responsible for these charges should they not be covered under your policy.
Nondiscrimination Statement
Caledonia Chiropractic Clinic complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex (including pregnancy, sexual orientation, and gender identity). Caledonia Chiropractic clinic does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex (including pregnancy, sexual orientation, and gender identity).
Caledonia Chiropractic Clinic:
Provides free aids and services to people with disabilities to communicate effectively with us, such as: written information in other formats (large print, audio, other formats). If you need these services, please contact the front desk or any employee of Caledonia Chiropractic Clinic
If you believe that Caledonia Chiropractic Clinic has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex (including pregnancy, sexual orientation, and gender identity), you can file a grievance with:
Timothy Schneider, D.C., 5401 Douglas Ave Racine, WI 53402 262-681-8829 [email protected]
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at https://www.hhs.gov/ocr/office/file/index.html.
Content created by Office for Civil Rights (OCR)
21st Century Cares Act
Our office still uses and maintains paper records therefore, we are unable to provide your records in an electronic format. If you wish to receive a copy of your records, we would be happy to provide them to you at no charge.
Massage Cancellation Policy
Arrival at our office:
Please arrive at least 5 minutes before your scheduled appointment time. If you are late for your appointment, your appointment will go only for the allotted time, and you will still be charged for the full session price.
Cancellation policy:
We ask that you provide us with a 24-hour notice when cancelling or rescheduling an appointment. Please understand that when you cancel or miss your appointment without providing 24-hour notice we are unable to fill that appointment time. This is inconvenient for the therapist and means other clients miss out on an appointment they would have liked. For this reason, you will be charged 50% of the massage appointment fee for the first missed appointment and 100% of the appointment charge for each session after that.
No show policy:
If you are a no call/no show for your massage appointment, you will be charged the full price of your appointment.
E -mail specials:
If you booked one of our last-minute email specials, and you cancel or do not show, you will be charged the full price of the appointment.
***An invoice will be sent, and the balance due must be paid in full before any future appointments can be scheduled. If a gift certificate was going to be used, it will be considered redeemed and voided.