Office Policy

Financial Policy & Procedures

This notice outlines the financial policies and procedures of The Back Alley Chiropractic & Massage. Please review it carefully. Contact our office with any questions (520) 877-2666. Office Policy updated 10/15/2025

Office & Financial Policy

Appointments We are a multiple provider office, and we often schedule multiple overlapping appointments according to the service requested and depending on the treatment required. We strive to minimize wait time; however, emergencies do occur and will take priority. We appreciate your understanding. If you are more than 5 minutes late for your appointment, we will do our best to accommodate you, but we may require you to reschedule. Walk-ins are welcome; however, appointments are encouraged and will always be seen first. If you have not been seen in our office in 18 months or longer, or if you have a new or different injury, a re-exam will be conducted and charged to you or your insurance carrier. If you have not been seen in our office in 3 years or longer, you are considered a new patient.

Balances Due Unpaid balances are past due at 30 days. Balances left unpaid may receive a second and third notice prior to final notice, mailed at 30-day intervals. The Back Alley Chiropractic utilizes an outside collection agency to collect balances over 120 days past due.

Fee Schedule Our current fee schedule is attached and can also be found on our website at any time. Fee schedules are regularly updated.

Insured As a courtesy to our patients, we will submit your in-network medical claim to your insurance carrier. Patient responsibility is due at time of service. Patient balances are billed immediately upon receipt of your insurance carriers Explanation of Benefits (EOB), and your remittance is due immediately upon receipt of our bill. We do not bill out-of-network claims. We do not bill secondary claims.

Medicaid/AHCCCS Effective October 1, 2022, the state of Arizona made additions and changes to Chiropractic coverage for Medicaid/AHCCCS recipients as follows: AHCCCS will cover up to 20 medically necessary chiropractic visits for adults each year. Services must be ordered by a primary care provider and within the scope of chiropractic practice as defined by state law. If you actively qualify for AHCCCS, a referral from your primary care provider (PCP) will be required before scheduling any appointments, regardless of patient status. According to Arizona state law, a provider with an AHCCCS contract is required to bill AHCCCS for any covered service(s). In addition, Arizona state law does not allow AHCCCS recipients to opt-out of using their coverage at a provider’s office for covered services.

Medicare We are a participating Medicare provider accepting Medicare assignment. As a Medicare patient you are responsible for your deductible and co-insurance. If you have secondary or supplemental insurance, you must insure you have signed up for Medicare crossover in order for the full claim to be covered by both carriers. Our office does not bill supplementary or secondary carriers. Medicare non-covered services are due at the time of service. According to federal law, unlike other medical providers, Chiropractors cannot opt-out of the Medicare program, therefore, Medicare beneficiaries cannot opt-out of using their coverage in our office.

Medicare Advantage Medicare Advantage is an alternative to traditional Medicare. Plans operate under the same rules as traditional Medicare, but coverage is provided through a commercial insurance carrier, and your Medicare Part B benefits no longer apply. Some plans may offer additional benefits that are not included under traditional Medicare, however many services rendered in a chiropractor’s office continue to be non-covered and are due at the time of service.

Payment We accept cash, personal check, debit, and Visa, MasterCard and Discover. If you forget your form of payment, we may require you to reschedule. A surcharge of 3% is imposed on all brands of credit card transactions, that is not greater than our cost of acceptance. There is a minimum fee of $40 charged for returned checks.

Personal Injury Claims We bill third party insurance carriers only on a lien basis. Please notify our staff of your personal injury immediately. You will be asked to complete forms specific to personal injury as well as a consent and notice for medical lien. By consenting to Medical Lien, you elect not to use any coverage potentially available under a health insurance or similar medical benefit plan that may cover you, the injured, as an insured or dependent. By consenting to Medical Lien, you elect to opt-out of any Prompt Pay discount available to you and payable at the time of service for each date of service.

Prompt Pay We offer a Prompt Pay discount for all patients by request. If you fail to provide payment at the time services are rendered, you will be responsible for and billed 100% of the professional fee. A copy of our fee schedule can be found on our website at any time. You may also request a copy at the front desk. Insurance cannot be used when opting for a Prompt Pay discount.

Self-Pay We offer affordable self-pay rates to all patients under the Prompt Pay discount, with the requirement that payment be made at the time service is rendered. If you are insured and elect to self-pay you will be required to sign a separate form electing to opt-out of utilizing potential coverage. If you are self-pay and fail to provide payment at the time service is rendered, you will be responsible for and billed 100% of the professional fee. Medicaid/AHCCCS members cannot elect to self-pay. Medicare Beneficiaries cannot elect to self-pay.

Workers Compensation If you are here because of a work related injury, please be aware that very specific paperwork is necessary to ensure your treatment is covered under your employer’s plan. If you have completed a report of injury with your employer, retain a copy for your records, we will require this at your first visit. Many worker’s compensation insurance carriers require authorization or referral for chiropractic treatment, which must be received in our office before scheduling your initial appointment.

Insurance Policy & Procedures

• Many insurance companies have defaulted to utilizing “electronic” ID cards and are no longer sending paper or plastic copies in the mail. While this has become standard practice, The Back Alley Chiropractic’s contract with your insurance company still requires that we obtain a copy of your insurance card and identification card for each visit. Our standing policy to comply with these requirements is to scan your insurance card(s) and identification card at your initial visit, and a minimum of once a year thereafter. Electronic ID cards should be emailed to thebackalleychiro@yahoo.com.
• The Back Alley Chiropractic fully complies with all our insurance contracts. It is not our custom to balance bill amounts not allowed by your insurance policy. It is your responsibility to update us with your current insurance information. If you fail to notify us of a change in carrier, termination of coverage, and/or exceeded benefits, you will be 100% responsible for payment per your insurance policy’s allowable amount.
• The Back Alley Chiropractic strives to contract with local insurance plans, however due to special cases this may not be possible. If we are not contracted with your plan, we are not under any legal obligations to submit a claim. In the interest of keeping costs as low as possible for all parties, we will not submit claims for out-of-network benefits. If you opt to seek reimbursement directly from your plan, we will be happy to provide an itemized statement at your request.
• Chiropractic care is designated as specialty care under many insurance plans. It is your responsibility to know if a referral or pre-authorization is required to see specialists. If a referral is required, it is up to you to arrange the submission per your insurance carrier by your primary care provider (PCP).If a referral or authorization is not received prior to your appointment, your appointment will be cancelled or rescheduled until services have been properly authorized.
• The Back Alley Chiropractic does its best to verify and interpret your benefits and eligibility specific to chiropractic and therapeutic procedures. Occasionally we are given incorrect information by human beings. As human beings ourselves, we too can make mistakes. In any case, you are responsible for balances owed if your Explanation of Benefits (EOB) shows a different amount owed from your verification. Any questions about balances owed should be directed to your insurance carrier’s member services, which can be found on the back of your insurance card or on your EOB.
• According to your insurance carrier, you are responsible for co-pays, deductibles, and/or co-insurances. Co-pays, deductibles, and/or co-insurances are fees that legally cannot be waived or discounted. You will be responsible for your portion of the bill, which is payable at the time of service at each visit. As such, copays, deductibles, and/or co-insurances cannot be paid in advance. In the rare case your insurance carrier is to be billed prior to payment collection, once we receive an EOB from your insurance carrier an itemized bill will be sent to you with any balance owed per your insurance plan.
• Any insurance you may have is an agreement between you and your insurance carrier and you are financially responsible for the payment of any services rendered.
• According to your insurance carrier, verification of your benefits is not a guarantee of payment and final determination will be made for payment of services after a claim is received. The Back Alley Chiropractic is committed to providing the best treatment for our patients. Our professional fees are usual and customary per local state and federal rate tables.

2026 FEE SCHEDULE

No one enjoys receiving surprise bills. This fee schedule is provided so that you will be aware of all charges that can be accrued for services rendered and provided. This fee schedule is updated regularly. You may request a copy of this fee schedule from our front desk.

*We offer a Prompt Pay Fee for all patients by request, in lieu of insurance coverage. Insurance cannot be used when opting for a Prompt Pay Fee. If you opt to utilize the Prompt Pay Fee and fail to provide payment at the time services are rendered, you will be responsible for and billed 100% of the professional fee. Fee schedule updated 10/08/2025.

Questions regarding this fee schedule may be directed to our office at (520) 877-2666.

What is a CPT® code?

CPT is designated by the U.S. Department of Health and Human Services under the Health Insurance Portability and Accountability Act (HIPAA) as a national coding set for physician and other health care professional services and procedures, CPT’s evidence-based codes accurately encompass the full range of health care services.

What are E/M codes?

E/M services represent a category of CPT codes called Evaluation and Management. E/M services are a type of patient encounter between a physician and a patient seeking medical advice and care for symptoms, conditions, illnesses, or injuries. Commonly, E/M services are face-to-face encounters between the provider and patient. There are different levels of E/M codes, which are determined by the complexity of a patient visit and documentation requirements.

What are CMT codes?

As explained by CPT guidelines, Chiropractic Manipulative Treatment (CMT) is a form of manual treatment to influence joint and neurophysiological function. CMT services are represented by a category of CPT codes used to indicate the number of spinal regions manipulated. Spinal regions as defined by CPT are: Cervical, Thoracic, Lumbar, Sacral, and Pelvic. Extraspinal (non-spinal) regions as defined by CPT are: Head, Upper extremities, Rib cage, Abdomen, and Lower extremities.

What is Therapy?

Therapeutic procedures are modalities (specific types of treatment) that can be used in conjunction with CMT to assist with a variety of conditions or injuries.

massage policy

Your well-being is very important to us. Our goal is to provide quality health care to all our patients in a timely manner. We do understand that sometimes unexpected delays or emergencies can occur. Please be aware of our policy regarding massage appointments. As a necessary business practice this policy is enforced. Massage policy updated 10/15/2025.

Why do we have a Massage Therapy Policy? No-shows, late arrivals, and cancellations inconvenience not only our providers, but our other patients as well. When you book your appointment, you are holding a space on our calendar that is no longer available to our other patients.

What can I do? In order to be respectful of your fellow patients, please call our office at (520) 877-2666 as soon as you know you will not be able to make your appointment.

Once you have booked a massage appointment with us it means that we have reserved our therapist’s time exclusively for you. We understand that unanticipated events happen occasionally in everyone’s life. We value your business and strongly believe that your time is as valuable as ours. In our desire to be effective and fair to all clients and staff, massage appointments are subject to the following cancellation policy:

Cancellation Policy

Cancellation is free up to 24 hours in advance. Appointments are in high demand and your advanced notice will allow another patient access to that appointment time. New clients and/or first appointments that result in a no show or late cancellation will be charged 100% of the scheduled fee; otherwise, for existing clients after 24 hours a 50% late cancellation fee will be charged. Cancellation fee is based on the current fee schedule at the time cancellation occurs. Cancellations are payable by client only and due at the time of late cancellation/no show.

Late Cancellations/No-Shows

A cancellation is considered late when the appointment is cancelled less than 24 hours before the appointed time. A no-show is when a patient misses an appointment without cancelling. In either case, you will be responsible for a cancellation fee as outlined above.

How to Cancel Your Appointment

If you need to cancel or reschedule your appointment time, please call us at (520) 877-2666. If necessary, you may leave a voicemail message. Cancellation by text message is available by following the instructions on your original text reminder or by replying with a detailed text message. Cancellations by email cannot be accepted.

Prompt Pay Massage Fees

30 minutes $50.00              60 minutes $80.00              90 minutes $115.00            120 minutes $150.00

Prompt pay massage fees apply only to payments made at the time of service for massage appointments of 4+ units, any balance left unpaid, regardless of reason, is subject to the full professional fee of $25.00 per massage unit (15-minute interval). This policy applies to all pre-arranged non-pay at time of service agreements, i.e. third party payment, personal injury, MEDPAY, etc.

Appointment Reminders

As an added convenience, our office offers text message reminders. If you would like to sign up for this service, ask any member of our front desk to opt-in. In addition to this convenience, you can easily cancel an appointment by text message by following the instructions on your original text. Remember, a 24-hour notice is always required for any cancellations or appointment changes.

INFORMED CONSENT FOR CHIROPRACTIC TREATMENT

The nature of chiropractic adjustment. The primary treatment used by Doctor of Chiropractic is spinal manipulative therapy. The doctor will use that procedure to treat you. The doctor may use his hands or a mechanical instrument upon your body in such a way as to move your joints. That may cause an audible “pop” or “click,” much as you may experience when you “crack” your knuckles. You may or may not feel a sense of movement.

Analysis/Examination/Treatment. As a part of the analysis, examination, and treatment, you are consenting to the following procedures: spinal manipulative therapy, palpation, vital signs, range of motion testing, orthopedic testing, basic neurological testing, muscle strength testing, postural analysis testing, hot/cold therapy, EMS, physiotherapy, physical medicine, physical therapy, and radiographic studies.

The risks inherent in chiropractic adjustment. As with any health care procedure, there are certain complications that may arise during chiropractic manipulation and therapy. Those complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, muscle strain, cervical myelopathy, costovertebral strains and separations, and burns. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. Some patients can experience stiffness and soreness following the first few days of treatment. The doctor will make every reasonable effort during the examination to screen for contraindications to care; however, if you have a condition that would otherwise not come to the doctor’s attention it is your responsibility to inform the doctor.

The probability of those risks occurring. Fractures are rare occurrences and generally result from some underlying weakness of the bone which we check for during the taking of your history and during examination. Stroke and/or arterial dissection caused by chiropractic manipulation of the neck has been the subject of ongoing medical research and debate. The most current research on the topic is inconclusive as to a specific incident of this complication occurring. If there is a causal relationship at all it is extremely rare and remote. Unfortunately, there is no recognized screening procedure to identify patients with neck pain who are at risk of arterial stroke.

The availability and nature of other treatment options. Other treatment options for your condition may include: self-administered over-the-counter analgesics and rest, medical care, and prescription drugs such as anti-inflammatory, muscle relaxants and painkillers, hospitalization, surgery. If you choose to use one of the above noted “other treatment” options, you should be aware that there are risks and benefits of such options and you may wish to discuss these with your primary care physician.

The risks and dangers of remaining untreated. Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed.

records request & release

The are many reasons medical records may be requested. A patient has a legal right to view and/or request a copy of their medical records. The following policy was put into effect for our office to abide by HIPAA requirements as well as to allow the patient to assert their rights.

How may a patient view their records? A patient may request to schedule an appointment to view their records at any time. A member of the staff must be present with the patient at all times to ensure records are not tampered with or removed.

How may a patient request a copy of their records? A patient may request a copy of their medical records at any time by completing an Authorization for Protected Health Information form. The form must be completed with no blank spaces.

Is there a charge to copy records? Arizona law allows physicians to charge a reasonable amount for the cost of copying and mailing records.

How long does it take to process a request for medical records? Arizona law states we must process requests for records within 30 days of the request. Records may be faxed, mailed, or picked up.

Who else may request medical records? Other physicians, insurance companies, insurance carriers, and attorneys may request records at any time.

Is there a charge when other physicians, insurance companies, insurance carriers, and attorneys request records? Records requested by other physicians for continuing care can not be charged. Insurance companies, insurance carriers and attorneys may be charged per request, payable in advance. In some cases, health insurance companies which we are in network with can not be charged for records, or the patient is liable for the fee.

How can others request medical records? A signed request on letterhead or other office form from the requesting physician or facility, a Medical Authorization form signed by the patient, Subpoena of the court, Record’s Retrieval service.

Can a patient request records be sent to someone else? A patient may complete an Authorization for Protected Health Information with the name of the receiver on the request. Charges do not apply if the receiver is a physician, doctor office or hospital, and for the purposes of continuing care.