It is in your best interest, as a patient, to know and understand your insurance plan benefits and your responsibility for any deductibles, co-insurance, or co-payment amounts prior to any visit. Not all services are covered in all insurance contracts.
In addition, you should be sure that your physician is listed as a participating provider by your insurance company. If your insurance plan does not cover a service or procedure, you are responsible for payment of these charges. In the event that your insurance is not valid, or your coverage is not active at the time the services are rendered; you will be solely responsible for the full amount of your office visit and/or any procedures rendered.
In addition, if your insurance plan determines a service or procedure to be “not covered,” you will be responsible for the complete charge of such services.
We ask all patients to review and sign this policy, asking questions, as necessary. A copy will be provided to each patient upon request.
- Insurance: We accept assignment from most insurance plans and participate with Blue Cross Blue Shield, Aetna, Multiplan, First Choice Health and Cigna preferred provider fee schedules. It is the patient’s responsibility to know their insurance benefits and to know in/out of network status for our providers; Patients can check this by calling their insurance company. We will bill the insurance company as a courtesy to the patient and any service or procedure not covered by the policy will be patient responsibility. Any copay, deductible or co-insurance is due at the time of service. Any balance left on the account by the insurance company is patient responsibility and is due when the patient receives the first statement. Any refunds due to the patient will not be credited back until the insurance has paid on all claims in full.
- Medicare: We are non-participating providers in Medicare. Medicare only covers spinal manipulation in a chiropractic setting and will not cover the cost of the exam or any other treatment modalities such as massage therapy, heat, ice, electronic stimulation, TENS or exercise therapy. Medicare pay for 80% of the determined rate and the patient is responsible for the remaining balance if there is no secondary insurance.
- Patient payment: All co-payments and deductibles are to be paid at the time of service. This arrangement is part of your contract with your insurance company.
- Registration: All patients must complete our patient information registration, which will be entered into our computer to maintain accurate information for proper billing. We must obtain a copy of your driver’s license and current valid insurance card to provide proof of insurance. If you fail to provide us with the correct insurance information, or your insurance changes and you fail to notify us in a timely manner, you may be responsible for the balance of a claim. Most insurance companies have time filing restrictions; if a claim is not received within 30 days of the date of service, it can be rendered ineligible for payment and you will be responsible for the balance that remains.
- Claims: We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may not accept information from our office and may need information from you. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether your insurance company pays or not. Your insurance benefit is a contract between you and the insurance company; we are not party to that contract.
- Credit/Debit Cards on file: We require our patients to have a credit or debit card on file. This is used to process co-payments and deductibles. We will also be charging your card on file, if any remaining balance is due, 14 days after we send a statement to your email and/or personal PO Box. If you do wish to not be charged with the card on file, please let us know before that 14 day window ends or talk to us at your next appointment.
- Self-‐Insured/Uninsured patients and Non-‐Covered Services: We offer a 14% discount to our patients who do not have insurance and for charges for services that were considered as non-‐covered by insurance. Please be advised that the discount is only good when the charges are paid at the time of service. If the charges are not paid at the time of service, the discount will be removed, and payment of the full charge will be expected before the next visit. If you require a payment plan for your balance, we can arrange a 3-6 month payment plan for any remaining balance. Any account balance over 180 days will be subject to review for collection action.
- Credit and collection: If your account is more than 90 days past due, and if a balance has remained unpaid, it may be sent to a collection agency.
- No Show-‐Missed appointments: Our policy is to charge $40 for missed chiropractic appointments and $60 for missed massage appointments, this includes those not canceled more than 24 hours in advance. These charges will be your responsibility and billed directly to you. Please help us serve you better by keeping your regularly scheduled appointment. Under the circumstances when a traveling massage therapist is performing the massage, the entire balance of the appointment will be due at the time of scheduling and that charge is non-refundable if you no show the appointment.
- Work Comp Insurance Patients: We will bill the Workman’s Compensation carrier as a courtesy, but if the claim is denied due to non-compensable injury or as not work related the account balance will be patient responsibility regardless of any approvals before visits by your insurance company.
Thank you for understanding our financial policy. Please let us know if you have any questions or concerns. I have read and understand the financial policy and agree to abide by its guidelines.
Last Update 01/01/2021
Privacy and Health Information Policy
This Notice of Privacy Practices is provided to you by NORTHSTAR ALIGNMENT LLC (hereinafter “we” or “company”) as a requirement of the Health Insurance Portability and Accountability Act (HIPAA). It describes how we may use or disclose your protected health information, with whom that information may be shared, and the safeguard we have in place to protect it. This notice also describes your rights to access and amend your protected health information. You have the right to approve or refuse the release of specific information outside of our system except when the release is required or authorized by law or regulation.
Acknowledgement of Receipt of this Notice. You will be asked to provide a signed acknowledgement of receipt of this Notice. Our intent is to make you aware of the possible uses and disclosures of your protected health information and your privacy rights. The delivery of your health care services will in no way be conditioned upon your signed acknowledgement. If you decline to provide a signed acknowledgement, we will continue to provide your treatment, and will use and disclose your protected health information for treatment, payment, and health care operations when necessary.
Our Duties to You Regarding Your Protected Health Information (PHI). PHI is individually identifiable health information. This information includes demographics, for example, age, address, e-mail address, and relates to your past, present, or future physical or mental health or condition and related health care services. We are required by law to do the following:
- Make sure that your PHI is kept private;
- Give you this notice of our legal duties and privacy practices related to the use and disclosure of your PHI;
- Follow the terms of this notice currently in effect; and
- Communicate any changes in the notice to you.
Company reserves the right to change the terms of its notice and to make new notice provisions effective for all protected health information that it maintains. Company will provide each patient with a copy of any revisions of its Notice of Information Practice at the time of their next visit, or at their last known address if there is a need to use or disclose any protected health information of the patient. Copies may also be obtained at any time at our offices.
Permitted Uses: Treatment, Payment and Healthcare Operations. We may use and disclose protected health information for treatment, payment and healthcare operations. Treatment examples include, but are not limited to requested preschool, life insurance or sports physicals; referral to nursing homes, foster care homes, or home health agencies; or referrals to other providers for treatment. Payment examples include, but are not limited to completing a claim form to obtain payment from an insurer or activities that we might undertake to determine eligibility or coverage for benefits. Healthcare operations include, but are not limited to, investigations, implementing compliance programs, oversight or staff performance reviews, and internal quality control assurance including auditing of records.
Other Permitted Uses. Company is permitted or required to use or disclose protected health information without the individual’s written authorization in certain circumstances. These include the following:
- Required Uses and Disclosures. By law, we must disclose your health information to you unless it has been determined by a competent medical authority that it would be harmful to you. We must also disclose health information to the Secretary of the Department of Health and Human Services for investigations or determinations of our compliance with laws on the protection of your health information. We may use or disclose your PHI if a law or regulation requires the use or disclosure.
- Business Associates. We will share your PHI with third party “business associates” who perform various activities for us. Examples are billing services or transcription services. The business associates will be required to sign a Business Associate Agreement and they will be required to protect your health information.
- Contacting You. We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment. We may call you by name in the waiting room when your health care provider is ready to see you.
- Treatment Alternatives. We may use or disclose your PHI to provide you with information about treatment alternatives or other health-related benefits and services that might interest you. For example, your name and address may be used to send you a newsletter about services we offer. We may also send you information about products or services that might benefit you.
- Public Health. We may disclose your PHI to a public health authority who is permitted by law to collect or receive the information. The disclosure may be necessary to prevent or control disease, injury or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition. We may notify the appropriate government authority if we believe a patient has been a victim of abuse, neglect, or domestic violence.
- Communicable Diseases. We may disclose your PHI, if authorized by law, to a person who might have been exposed to a communicable disease or might otherwise be at risk of contracting or spreading the disease or condition.
- Health Oversight. We may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations and inspections. These health oversight agencies might include government agencies that oversee the health care system, government benefits programs, other government regulatory programs, and civil rights laws.
- Food and Drug Administration. We may disclose your protected health information to a person or company required by the FDA to do the following: report adverse events, product defects, or problems and biologic product deviations; tract products; enable product recalls; make repairs or replacements; or conduct post-marketing surveillance as required.
- Legal Proceedings. We may disclose PHI during any judicial or administrative proceeding, in response to a court order or administrative tribunal (if such a disclosure is expressly authorized), and in certain conditions in response to a subpoena, discovery request, or other lawful process.
- Law Enforcement. We may disclose PHI for law enforcement purposes, including responses to legal proceedings, information requests for identification and location, circumstances pertaining to victims of a crime, deaths suspected from criminal conduct, crimes occurring at our office site, and medical emergencies believed to result from criminal conduct.
- Coroners, Funeral Directors and Organ Donations. We may disclose PHI to coroners or medical examiners for identification to determine the cause of death or for the performance of other duties authorized by law. We may also disclose PHI to funeral directors if authorized by law. PHI may be used and disclosed for cadaveric organ, eye, or tissue donations.
- Research. We may disclose your PHI to researchers when authorized by law, for example, if their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your PHI.
- Criminal Activity. Under applicable federal and state laws, we may disclose your PHI if we believe that its use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose PHI if it is necessary for law enforcement authorities to identify or apprehend an individual.
- Military Activity and National Security. When the appropriate conditions apply, we may use or disclose PHI of individuals who are Armed Forces personnel (1) for activities believed necessary or appropriate military command authorities to ensure the proper execution of the military mission including determination of fitness for duty; (2) for determination by the Department of Veterans Affairs of your eligibility for benefits; or (3) to a foreign military authority if you are a member of that foreign military service. We may also disclose your PHI to authorized federal officials for conducting national security and intelligence activities including protective services to the President or others.
- Workers’ Compensation. We may disclose your PHI to comply with workers’ compensation laws and other similar legally established programs. We will act consistently with the law of the Commonwealth of Pennsylvania and will make disclosures following such laws.
- Inmates. We may use or disclose your PHI if you are an inmate of a correctional facility, and we created or received your PHI information while providing care to you. This disclosure would be necessary (1) for the institution to provide you with care, (2) for your health and safety or that of others, or (3) for the safety and security of the correctional institution.
- Parental Access. We may use or disclose PHI to parents, guardians and persons acting in a similar legal status. We will act consistently with the law of the Commonwealth of Pennsylvania and will make disclosures following such laws.
- Family Members. Unless you object, we may release protected health information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may also tell your family or friends the condition that you are in. You will be provided a form to list specific people who we may speak to regarding your medical care. In addition, we may disclose protected health information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
- Fundraising. Company may use protected health information about you to contact you in an effort to raise money for our practice and its operations. We may disclose protected health information to a related foundation so that the foundation may contact you in raising money. We only would release contact information, such as your name, address and phone number and the dates you received treatment or services. If you do not want us to contact you for fundraising efforts, you must notify our practice in writing.
Authorization Required. Company will not make any other use or disclosure of your protected health information without your written and valid authorization. Such use or disclosure must be consistent with such authorization. Authorization is specifically required for the following:
- Psychotherapy Notes. We must obtain an authorization for any use or disclosure of psychotherapy notes, except: to carry out the following treatment, payment, or health care operations: (A) use by the originator of the psychotherapy notes for treatment; (B) use or disclosure by the covered entity for its own training programs in which students, trainees, or practitioners in mental health learn under supervision to practice or improve their skills in group, joint, family, or individual counseling; or (C) use or disclosure by the covered entity to defend itself in a legal action or other proceeding brought by the individual.
- Marketing. We must obtain an authorization for any use or disclosure of protected health information for marketing, except if the communication is in the form of: (A) A face-to-face communication made by a covered entity to an individual; or (B) A promotional gift of nominal value provided by the covered entity. If the marketing involves financial remuneration to us from a third party, the authorization must state that such remuneration is involved.
- Sale of protected health information. We must obtain an authorization for any disclosure of protected health information which is a sale of protected health information. The authorization must state that the disclosure will result in remuneration to the covered entity.
Revoking Authorization. You may revoke the authorization at any time provided that the revocation is in writing, except to the extent that: (A) we have not taken action in reliance thereon or (B) if the authorization was obtained as a condition of obtaining insurance coverage, other law provides the insurer with the right to contest a claim under the policy or the policy itself.
Patient Rights. Patients have been granted individual rights under the HIPAA Legislation. These include the following:
- Inspect and copy. You have the right to inspect and copy protected health information that may be used to make decisions about your care. You have the right to a paper copy. Usually, this includes medical and billing records, but does not include psychotherapy notes, information complied in reasonable anticipation of or use in a civil, criminal or administrative action or proceeding, or Protected Health Information that is subject to or exempt from the Clinical Laboratories Act of 1988. To inspect and copy protected health information that may be used to make decisions about you, you must submit your request in writing us. If you request a copy of the information, we may charge a fee for the costs of copying (including labor), mailing or other supplies associated with your request.
- Amend. If you feel that protected health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is maintained in the designated record set. To request an amendment, your request must be made in writing and submitted to us. You must provide a reason that supports your request and we may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that was not created by us, unless the person or entity that created the information is no longer available to make the amendment, is not part of the protected health information kept by or for our practice; is not part of the information which you would be permitted to inspect and copy; or is accurate and complete. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to protected health information, you may request that the denial be reviewed. Another licensed health care professional chosen by our organization will review your request and the denial. The person conducting the review will not be the person who denied your request and we will comply with the outcome of the review.
- Accounting of disclosures. You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of protected health information about you that was not made for treatment, payment and health care operations and there are certain exceptions to this right. To request this list or accounting of disclosures, you must submit your request in writing to us. Your request must state a time period, which may not be longer than six years prior to the date you request the accounting. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. The accounting must be provided to you no later than 60 days after the receipt of your request, unless we utilize the 30-day extension period.
- Restrictions on uses or disclosures. You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the protected health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to us. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse. Either you or we may terminate the restriction upon notification of the other.
- Confidential communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to us. We will ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
- Complaints. You may complain to us and to the Secretary of the Department of Health and Human Services if you believe that your privacy rights have been violated. It is Company’s policy that no retaliatory action will be made against any individual who submits or conveys a complaint of suspected or actual non-compliance of the privacy standards. You may file a Complaint with us by sending a written complaint to us.
You will be asked to outline or define specific instances or information that you would like kept completely confidential (between you and us). If you have any questions regarding this Notice of Privacy Practices, please do not hesitate to contact us for more information or clarification. You may contact the following:
Below are are fees and codes that we use to bill insurance companies and all of our patients. The contracts that we may or may not have with individual insurance carriers determines the price that is passed onto the patient.
All fees are subject to a 15% time of Service (TOS) discount if paid at the end of the appointment.
New Patient Exam
Code Description Fee
99201 Wellness Visit $70.00
99202 Basic Exam (5-15min) $120.00
99203 Intermediate exam (15-30min) $165.00
99204 Complex Exam (30-45min) $250.00
Established Patient Exam
Code Description Fee
99211 Re-evaluation $35.00
99212 New problem Basic $65.00
99213 New Problem Intermediate $110.00
99214 New Problem Complex $167.00
Code Description Fee
98940 CMT 1-2 Regions $45.00
98941 CMT 3-4 Regions $61.00
98942 CMT 5 Regions $80.00
98943 CMT Extra-spinal $40.00
97010 Ice/heat $8.00
97012 Mechanical Traction $25.00
97014 Electric Stim (per unit) $25.00
97026 Infrared $10.00
97032 Electric Stim – Attended (per Unit) $25.00
97035 Ultrasound (per Unit) $20.00
97039 Unlisted Modality $20.00
97110 Therapeutic Exercise $45.00
97112 Neuro-muscular Re-education $50.00
97114 Functional Activities $50.00
97139 Unlisted Therapy $15.00
97124 Massage Therapy (per 15 min) $45.00
97140 Manual Therapy (per 15 min) $45.00
In-House Codes: not reimbursable by insurance
Code Description Fee
MS001 Swedish Massage (per hour) $141.18