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Terms and Conditions
Terms and Conditions
Back in Motion Spine and Wellness Clinic
and Neuro Diagnostic Centers Inc.
Effective Date: September 21, 2026
DISCLAIMER — NOT LEGAL ADVICE
These Terms and Conditions are a sample office policy drafted for general informational and drafting purposes only. They are not legal advice, are not a legal opinion, and do not create an attorney-client relationship with any person or organization. Healthcare, consumer, insurance, collections, informed-consent, independent-medical-examination, and privacy requirements vary and change. The Practice must have a licensed Florida attorney review, revise, and approve this document before it is used with patients, examinees, or the public. Do not rely on this document as a substitute for professional legal counsel. Until counsel has approved a final version, treat all bracketed items, fee amounts, addresses, and optional clauses as placeholders only.
These Terms and Conditions (“Terms”) govern your relationship with Back in Motion Spine and Wellness Clinic and Neuro Diagnostic Centers Inc. (collectively, “the Practice,” “we,” “us,” or “our”), including chiropractic care, wellness services, spinal care, neurodiagnostic services, and independent medical examinations.
By scheduling an appointment, completing intake forms, signing an acknowledgment, receiving services, or using our website or patient communications, you agree to these Terms. If you do not agree, do not obtain services from the Practice.
1. Who We Are
The Practice provides chiropractic and related wellness services and, through Neuro Diagnostic Centers Inc., chiropractic independent medical examination and neurodiagnostic evaluation services. Services may include examination, consultation, spinal and extremity adjusting, rehabilitative or wellness therapies, diagnostic procedures as clinically indicated, and reports requested by patients, treating providers, insurers, attorneys, employers, or other authorized third parties.
Services are provided only by licensed professionals acting within the scope of Florida law and applicable professional board rules.
2. Not Emergency Care
We are not an emergency facility. If you have chest pain, sudden severe headache, loss of consciousness, sudden weakness, difficulty speaking, uncontrolled bleeding, or any other emergency, call 911 or go to the nearest emergency department.
3. Eligibility and Authority
You represent that the information you provide is accurate and complete. If you are booking or consenting for a minor or an incapacitated adult, you represent that you are the parent, legal guardian, or legally authorized representative and that you have authority to consent to care and to accept financial responsibility.
A parent or legal guardian must accompany minors unless we agree otherwise in writing and Florida law permits the visit.
4. Nature of Care; No Guarantee
Chiropractic and wellness care may include history, examination, imaging or other testing when indicated, manual or instrument-assisted adjustment, soft-tissue work, exercise instruction, and related therapies.
Outcomes vary. We do not guarantee pain relief, cure, specific clinical results, work status, disability rating, legal outcome, or insurance payment.
You may refuse any recommended procedure. You should tell us immediately about new or worsening symptoms, prior spinal surgery, osteoporosis, cancer, inflammatory arthritis, blood-clotting disorders, use of blood thinners, pregnancy, dizziness, numbness, weakness, or any other condition that may affect safety.
A separate informed-consent form may be required before examination or treatment. These Terms do not replace that consent.
5. Independent Medical Examinations and Third-Party Evaluations
Neuro Diagnostic Centers Inc. and, when applicable, the Practice may perform independent medical examinations (IMEs), impairment evaluations, records reviews, or similar services requested by an insurer, attorney, employer, or other third party.
For those services:
- The examinee is not necessarily a treating patient of the Practice.
- The purpose is evaluation and reporting, not ongoing treatment, unless separately agreed.
- The requesting party may receive the report according to the engagement and applicable law.
- The examinee remains responsible for providing accurate history and cooperating with the examination.
- Missed IME appointments may result in a missed-appointment fee billed to the requesting party, the examinee, or both, as stated in the scheduling notice or engagement letter.
- We do not provide legal advice and do not guarantee that a report will support any particular claim, defense, or rating.
Florida patient-record confidentiality still applies as required by law. See our Notice of Privacy Practices.
6. Appointments, Late Arrival, Cancellation, and No-Shows
Appointment times are reserved for you. Please arrive a few minutes early to complete or update paperwork.
Late arrival. If you arrive late, we may shorten the visit so later patients are not delayed, or we may require you to reschedule. A shortened visit may still be billed according to services actually provided.
Cancellation / reschedule. We require at least 24 hours’ notice to cancel or reschedule a regular office visit. Diagnostic procedures, extended evaluations, and IMEs may require 48 hours’ notice.
Late cancel / no-show. A cancellation with less than the required notice, or failure to appear, may result in a fee. Suggested amounts (insert the amounts you will actually charge after legal review):
- Regular chiropractic or wellness visit: $[25]
- Extended evaluation, therapy visit, or procedure: $[75]
- IME or reserved block of time: $[150] or the amount stated in the scheduling notice
These fees are not typically covered by insurance and are your responsibility (or the responsibility of the party that reserved the IME, as applicable). Repeated late cancellations or no-shows may result in prepaid-only scheduling or discharge from the Practice.
We may make exceptions for documented emergencies at our discretion.
7. Fees, Insurance, and Financial Responsibility
You are financially responsible for all services provided to you, including copayments, coinsurance, deductibles, non-covered services, denied claims, and cancellation/no-show fees.
Payment at time of service. Copays and self-pay amounts are due at the time of service unless we agree otherwise in writing. We accept [cash, check, and major credit/debit cards — insert accepted methods].
Insurance. If we bill insurance as a courtesy:
- You must provide current insurance information before or at the visit.
- Verification of benefits is not a guarantee of payment.
- You must know your plan’s chiropractic limits, referral or authorization requirements, and in-network status.
- You remain responsible for any amount not paid by the plan, except where law prohibits balance billing.
Assignment of benefits. You authorize the Practice to submit claims and to receive payment directly from your insurer, auto carrier, workers’ compensation carrier, or other payer when permitted. You assign to the Practice applicable benefits for services rendered.
Personal injury / PIP / workers’ compensation. You must tell us if the visit relates to an automobile accident, work injury, or other third-party claim. Florida personal-injury-protection and workers’ compensation rules may affect billing, reporting, and records release. You remain responsible if the claim is denied, exhausted, or not covered.
Returned payments. A returned-check or declined-payment fee of $[35] may apply.
Past-due accounts. Unpaid balances may accrue interest at the maximum rate allowed by Florida law after [30/60/90] days. We may place a hold on future appointments, require prepayment, or refer the account to collections. You agree to pay reasonable collection costs, including agency fees and attorneys’ fees, to the extent permitted by law.
Records fees. Copies of records are subject to our Notice of Privacy Practices and Florida § 456.057. We do not condition release of your records on payment of unpaid treatment charges.
Fee schedules may change. Current fees are available at the front desk.
8. Patient Responsibilities
You agree to:
- Provide a complete and honest health history and update it when it changes
- Follow agreed care recommendations or tell us if you cannot
- Take prescribed home exercises only as instructed
- Treat staff and other patients with respect
- Supervise children in the waiting area
- Keep payment and insurance information current
- Notify us of any legal, insurance, or workers’ compensation matter related to your care
9. Conduct and Right to Refuse or Discontinue Care
We may refuse to treat, discontinue a visit, or discharge a patient for nonpayment, repeated no-shows, abusive or threatening behavior, refusal to follow safety instructions, fraudulent information, or any situation that makes continued care unsafe or inappropriate. We will provide applicable notices required by professional rules and, when appropriate, assistance with transfer of records.
10. Privacy and Communications
Use and disclosure of health information are described in our Notice of Privacy Practices, which is incorporated by reference.
You consent to ordinary appointment reminders and billing communications by phone, text, voicemail, or email at the numbers and addresses you provide. Message and data rates may apply. You may opt out of text or email reminders by notifying the office; opting out does not cancel these Terms or your financial obligations. Do not send emergency messages by text or email.
11. Website, Online Booking, and Intellectual Property
If you use our website, portal, or online scheduling tools, you agree to use them only for lawful purposes and not to attempt unauthorized access. Website content is for general information and is not medical advice or a substitute for an in-person evaluation.
All Practice names, logos, forms, educational materials, and website content are owned by the Practice or its licensors and may not be copied for commercial use without permission.
12. Photographs, Reviews, and Testimonials
We will not use your identifiable photo, video, or testimonial for marketing without your separate written authorization. You may leave public reviews; you should not include other patients’ information or detailed medical facts you do not wish to make public.
13. Limitation of Liability
To the fullest extent permitted by Florida law, the Practice and its owners, doctors, employees, and agents are not liable for indirect, incidental, special, or consequential damages arising from scheduling, billing, website use, or non-clinical administrative services.
Nothing in these Terms limits liability that cannot be limited under Florida law, including liability for intentional misconduct. Clinical negligence claims remain subject to applicable Florida medical-malpractice and pre-suit requirements.
14. Indemnification
You agree to indemnify and hold the Practice harmless from claims, losses, and reasonable attorneys’ fees arising out of your breach of these Terms, your provision of false information, or your misuse of our website or communications systems, except to the extent caused by our willful misconduct.
15. Changes to These Terms
We may update these Terms at any time. The current version will be posted in the office and/or on our website and provided upon request. Continued scheduling or receipt of services after the effective date of a revision constitutes acceptance of the revised Terms, except where a signed agreement requires a different process.
16. Governing Law and Venue
These Terms are governed by the laws of the State of Florida, without regard to conflict-of-law rules. Exclusive venue for disputes arising out of these Terms or services provided in Florida shall be the state courts located in Volusia County, Florida, unless another venue is required by law (including applicable malpractice venue rules).
17. Severability and Entire Agreement
If any provision of these Terms is held unenforceable, the remaining provisions remain in effect. These Terms, together with your intake forms, informed-consent forms, financial policy acknowledgments, IME engagement letters, and our Notice of Privacy Practices, make up the agreement between you and the Practice. They supersede prior informal statements about office policies.
18. No Legal, Insurance, or Disability Advice
Nothing in these Terms, on our website, in educational materials, or in conversation with staff is legal advice, insurance advice, or a determination of disability, work capacity, or claim value. Questions about lawsuits, settlements, coverage disputes, or benefits should be directed to your own attorney or insurer.
19. Contact
Back in Motion Spine and Wellness Clinic and Neuro Diagnostic Centers Inc.
766 Deltona Blvd
Deltona, FL 32725
Phone: (386) 575-4001 Fax: (386) 575-4023
Questions about these Terms should be directed to the office manager or Privacy Officer.
Acknowledgment
I have read and understand these Terms and Conditions, including the disclaimer that this document is not legal advice to me and is an office policy of the Practice. I agree to be bound by these Terms. I understand that I am financially responsible for services and fees described above and that chiropractic and evaluation services do not guarantee a particular result.
Patient / Examinee name: ________________________________
Signature: ______________________________ Date: __________
Parent / Legal representative (if applicable): ______________
Relationship: ____________________________ Date: __________
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