Fee Schedule

From The Desk Of:
Dr Robert C Slater BA: Bachelor of Arts, MSc: Master of Anatomy, DC: Doctor of Chiropractic, CME: Federally Certified Medical Examiner, DACO: National Diplomate of Orthopedic, Certified Nutritionists:

Healing Hands Wellness: 631 South Cleveland Ave, St Paul MN 55116, ph: 651-699-3366; Fx: 651-699-5780: email: ezekarnak99@gmail.com: website: healinghandschiro.com

Patient Consent and Notice of Non-Covered Chiropractic or Physio-Therapy Treatment

I consent to the commencement of chiropractic care to correct vertebral misalignment of the spine [or any other joint]. Manual or activator adjustments re-center spinal segments, reduce its associated unequal ligament tensions, uneven disc pressures that all create spinal nerve stress. I will faithfully and in full compliance follow of Dr Slater DC’s instructions and full recommendations of care to fix this painful and disabling spinal and or extremity joint condition until maximum medical achievement is attained. I acknowledge that Dr Robert C Slater DC has explained the nature of my problem/condition and agree with his answers to my questions. I accept and understand that chiropractic care is essentially the manual adjustment of spinal segments or extremity joints by the hand of a doctor, and like any mechanical problem, ongoing periodic spinal adjustments are required to maintain the benefits of maximal spinal health.

Patient Expectations: you can expect to be received in a prompt, friendly and professional manner at all times, receive state of the art spinal/extremity treatment, and be assured the knowledge that staff and doctors at this clinic are your health partners for life.

Non-Insured Cash Fee and or Membership Schedules: If my annual deductible has not been met at the time of my treatment, I consent to pay the amount allowable by my insurance provider for each procedure of chiropractic care provided. I will pay at the time of service directly to the providing physician. The average amount of service allowed by insurances is noted below. All schedules noted below are agreeable by patient and this is sufficient authority, given the full disclosure of regular fees, for any such discounted fee payment to occur. Initial or Single Visit Adult Fee Schedule: [multiple family member = additional 10.00 discount per person of any age]

$45.00 ($145.00) [99203] for examination/consultation [69% discount]
$34.00 ($109.00) [99213] for re-examination/consultation [69% discount]
$30.00 ($75.00) [98941] for 3-4 Region Chiropractic Manipulative Treatment [60% discount]
$22.00 ($55.00) [98943] for Extremity/Cranial Chiropractic Manipulative Treatment [60% discount]
$12.00 ($40.00) [97010] for modality [Hot/cold, EMS, US, mechanical traction] [70% discount]
$15.00 ($50.00) [97140] for procedure [manual traction, manual therapy) [70% discount]
$20.00 ($65.00) [97110] per service [exercise therapy/instruction] [70% discount]

Plan Selected: ………………………………………………………………………………………………………………………………
I agree to this plan and understand my payment responsibility: ………………………………….………..….
Patient’s Printed Name and Signature: …………………………………… ……….………………..…Date……….....
Doctor’s Printed Name and Signature: ……………………………………. …………………………….Date.............

Healing Hands Wellness: 631 South Cleveland Ave, St Paul MN 55116, ph: 651-699-3366; Fx: 651-699-5780: email: ezekarnak99@gmail.com: website: healinghandschiro.com

Time Of Service Fee Schedule: Single Membership Three Month Fee Plan

Single Adult Membership Plan: based on the cap cost, a membership plan is an extended discount for chiropractic services for a maximum of 3 months, depending on a patient’s health status and diagnosis, for any “member” fees apply after a fixed cap for the first visit.

Discounted membership visits scheduled during any one week but missed do not transfer between weeks and no refunds on missed visits will be given. Exceptions may be considered for personal illness, family issues or work difficulties. Termination of a weekly membership plan by the patient requires a 1 week notice and incurs a $50.00 cancellation fee.

Single Membership Plan A: Three month plan with 24 visits scheduled 2* per week at $40.00 per visit:
Initial: $83.00 +23 visits: $960.00 + [2 re-evaluations at no-cost].

Payment Options Every 2 Weeks: (1) Initial payment: 50% = $480.00, (2) Second payment 30% = $317.00, (3) Third payment 20% = $192.00

Payment Options: (1) Initial payment: 50% = $227.50, (2) Second payment 30% = $136.5, (3) Third payment 20% = $91.00

Single Visit Discounted Adult Fee Schedules: [multiple family member = additional 10.00 discount per person of any age].