Terms and Conditions - Back 2 U

Patient Terms, Financial Policy, and Office Conditions

Effective Date: September 12, 2026

Practice Legal Name: Back 2 U Mobile Chiropractic

Practice Address: 13956 US Highway 87 S, Adkins, Texas 78101

Phone: 210-471-9661

Email: drlisamonsivais@gmail.com

Please read these Patient Terms, Financial Policy, and Office Conditions carefully. These terms explain important administrative, financial, and office policies for Back 2 U.

These terms do not replace an individualized examination, diagnosis, treatment plan, informed-consent discussion, or any separate clinical consent form.

1. Practice Sservices

Back 2 U provides chiropractic services within the scope of practice permitted by Texas law and the professional judgment of the treating chiropractor.

Care recommendations are individualized. The practice does not guarantee a particular clinical outcome, pain reduction, insurance payment, recovery period, or result from any examination, treatment, adjustment, exercise, product, or service.

If your condition is outside the chiropractor’s scope of practice, abilities, or clinical limitations, we may recommend referral to an appropriate health-care professional or facility.

2. Informed Consent

Before treatment, you will have the opportunity to discuss the proposed care, expected benefits, material risks, reasonable alternatives, and the option of declining care.

You may ask questions at any time and may refuse or discontinue treatment, subject to appropriate clinical and administrative procedures.

Your signature on this document confirms acknowledgment of office and financial policies only. It is not a substitute for a separate informed-consent discussion or treatment consent.

3. Appointments and Cancellations

Appointments are reserved specifically for you. If you need to reschedule or cancel an appointment, please provide at least 24 hours’ notice.

A missed appointment or late cancellation may result in a charge of $50.00, to the extent permitted by applicable law and any applicable insurance agreement. This charge is not billed to insurance unless allowed by your health plan and applicable law.

We may waive a missed-appointment fee at our discretion for emergencies or other appropriate circumstances.

Repeated missed appointments, late cancellations, failure to follow office procedures, or disruptive conduct may result in limitations on future scheduling or discharge from non-emergency care, consistent with applicable law and patient-safety obligations.

4. Financial Responsibility

You are responsible for payment for services and products provided by Back 2 U, including:

• Copayments;
• Coinsurance;
• Deductibles;
• Noncovered services;
• Charges denied by insurance because of benefit limitations, lack of authorization, lack of medical necessity determination by the payer, incorrect or inactive coverage information, or other plan rules;
• Charges for self-pay services;
• Approved fees for records, forms, reports, or other administrative services; and
• Any separately disclosed products, braces, supports, supplements, or patient aids.

Payment is due at the time services are rendered unless Back 2 U has agreed otherwise in writing.

We accept the following payment methods: [Cash / Check / Credit Card / Debit Card / HSA / FSA / Other].

Returned checks or reversed payments may result in a charge of $50.00 to the extent allowed by law.

5. Insurance

As a courtesy, Back 2 U may submit claims to your health plan when we are able to do so. Submission of a claim does not guarantee payment.

You are responsible for verifying your insurance coverage, benefits, referral requirements, authorization requirements, network status, deductible, copayment, coinsurance, and coverage limits.

Insurance benefits are determined by your health plan, not by Back 2 U. Any benefit estimate is not a guarantee of payment.

If your insurer does not pay all or part of a claim, you remain responsible for the patient balance unless prohibited by a written agreement between Back 2 U and your health plan or by applicable law.

If Back 2 U is contracted with your insurer, your financial responsibility will be determined in accordance with the applicable payer agreement and your health-plan benefits.

6. Self-Pay Services

Patients without insurance coverage, patients choosing not to submit a claim, and patients receiving noncovered services are responsible for the self-pay amount disclosed by the practice.

Current self-pay fees are available upon request. Any quoted fee applies only to the services described and may change for future services upon notice.

7. Prepaid Care, Care Packages, and Payment Plans

If Back 2 U offers a prepaid treatment plan, care package, payment plan, wellness plan, membership, or other financial arrangement for chiropractic services, the arrangement will be documented separately in writing.

For any prepaid arrangement, the written agreement will clearly state:

• The services included;
• The defined number of visits, if applicable;
• The total cost and payment terms;
• Any discount applied;
• Beginning and ending dates, treatment frequency, and relevant treatment-plan details when required;
• Whether products, braces, supports, supplements, or other tangible goods are included or separately billed;
• The process for cancellation; and
• The method for calculating any refund.

Unless a separate written agreement provides greater patient protections, a prepaid chiropractic treatment plan may be canceled by either party at any time and without a penalty to the patient. Upon cancellation, Back 2 U will refund the unused portion of prepaid chiropractic-service fees on a pro-rata basis based on services actually provided compared with the services contracted, subject to applicable law and any properly disclosed charge for separately purchased goods that have been provided.

Prepaid arrangements are voluntary. No patient is required to prepay for care as a condition of receiving clinically appropriate chiropractic services.

Prepaid arrangements do not override insurance contracts, insurance laws, fraud-and-abuse laws, or other applicable legal requirements.

8. Products, Braces, Supports, and Supplements

Products, braces, supports, supplements, and patient aids, if offered, may be billed separately unless a written agreement states they are included in the price of a treatment plan.

You are not required to purchase a product from Back 2 U in order to receive chiropractic services unless the product is clinically necessary and this is explained to you.

Products may have separate return, exchange, or warranty conditions. Any product-specific policy will be provided at the time of purchase.

9. Medical Records and Privacy

Your chiropractic records are confidential and will be handled according to our Notice of Privacy Practices and applicable federal and Texas law.

You may request access to or copies of your records by submitting a written request to the practice. We may charge a reasonable fee where permitted by law.

We may release records only with your valid written authorization or as otherwise permitted or required by law.

10. Communications

By providing your contact information, you authorize Back 2 U to contact you regarding appointments, scheduling, billing, account matters, and care coordination using the contact methods you provide.

You may request reasonable confidential-communication preferences, such as contact at a different phone number, email address, mailing address, or through a patient portal.

Text messages and ordinary email may not be fully secure. Do not use text messages or ordinary email for urgent medical concerns.

You may opt out of nonessential electronic communications by notifying us in writing. Opting out of appointment reminders or billing messages may affect our ability to communicate efficiently with you.

11. Emergencies

Back 2 U is not an emergency medical facility. Do not use the office, website, voicemail, email, text messaging, or patient portal for emergency care.

If you believe you are experiencing a medical emergency, call 911 or go to the nearest emergency department.

12. Patient Conduct and Safety

For the safety and dignity of patients, visitors, and staff, Back 2 U may require respectful behavior in the office and during communications.

Threatening, abusive, discriminatory, harassing, or unsafe conduct may result in removal from the premises, involvement of law enforcement when appropriate, and discharge from non-emergency care consistent with applicable law.

13. Website Information

Information on Back 2 U’s website, social-media pages, advertisements, newsletters, or educational materials is general information only. It is not individual medical advice, does not create a doctor-patient relationship, and should not be used as a substitute for an in-person evaluation by a qualified health-care professional.

Do not rely on website content to diagnose, treat, cure, or prevent a medical condition.

14. Changes to These Terms

Back 2 U may update these terms from time to time. Updated terms apply prospectively and will be made available at the office, through our patient forms, or on our website if applicable.

A change will not alter the financial terms of an existing prepaid agreement unless both parties agree in writing or a change is required by law.

15. Governing Law

These terms are governed by the laws of the State of Texas, except where federal law applies.

Questions or Complaints

For questions, requests, or complaints about this Notice or our privacy practices, contact: