Full Patient Policies and Consents

Althoff Wellness Clinic PC  |  Windsor, CO and Cheyenne, WY

Reference copy. The New Patient Consent Summary & Signature Page is the document you sign. If you would like to review any of these in full before you sign, or keep a copy for your records, just ask our staff, we're happy to provide it.

Notice of Patient Privacy Policy

This notice describes how medical information about you may be used and disclosed, and how you can get access to this information. Please review it carefully. If you have any questions about this Notice please contact our Privacy Officer or any staff member in our office.

Our Privacy Officer is: Dr. Jill Althoff

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out your treatment, collect payment for your care and manage the operations of this clinic. It also describes our policies concerning the use and disclosure of this information for other purposes that are permitted or required by law. It describes your rights to access and control your protected health information. "Protected Health Information" (PHI) is information about you, including demographic information that may identify you, that relates to your past, present, or future physical or mental health or condition and related health care services.

We are required by federal law to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice at any time. The new notice will be effective for all protected health information that we maintain at that time. You may obtain revisions to our Notice of Privacy Practices by accessing our website https://drjillalthoff.com, calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

A. Uses and Disclosures of Protected Health Information

By applying to be treated in our office, you are implying consent to the use and disclosure of your protected health information by your doctor, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to bill for your health care and to support the operation of the practice.

Treatment:

We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party that has already obtained your permission to have access to your protected health information. For example, we would disclose your protected health information, as necessary, to another physician who may be treating you.

Payment:

Your protected health information will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you, such as determining eligibility or coverage and reviewing services for medical necessity.

Healthcare Operations:

We may use or disclose, as needed, your protected health information in order to support the business activities of this office. These activities may include quality assessment activities, employee review activities, and training of students. We will share your protected health information with third party "business associates" that perform various activities (e.g., billing, transcription services, and technology services for the practice) under a signed Business Associate Agreement.

Documentation and Communication Technology:

As part of our healthcare operations, our office may use approved software tools to assist with accurately documenting your visit and with drafting routine patient communications. Any such tool is used only in connection with a signed Business Associate Agreement, and content assisted by these tools is reviewed and approved by a qualified member of our team before it becomes part of your care or is sent to you. We may also communicate with you electronically, including by secure email and by text message. Details on electronic communication are provided in our separate HIPAA Consent and Acknowledgement Form.

Uses and Disclosures Made Only With Your Written Authorization:

Disclosures of psychotherapy notes, uses and disclosures for marketing purposes, and disclosures that constitute a sale of Protected Health Information will be made only with your written authorization. You may revoke any authorization at any time, in writing, except to the extent your doctor or the practice has already acted in reliance on it.

B. Your Rights

You have the right to inspect and copy your protected health information, request a restriction on its use or disclosure, request confidential communications by an alternative means, request an amendment to your record, receive an accounting of certain disclosures, and be notified of any breach of your Protected Health Information. You have the right to obtain a paper copy of this notice at any time.

C. Complaints

You may complain to us, or to the Secretary of Health and Human Services, if you believe your privacy rights have been violated. Our Privacy Officer is Dr. Jill Althoff. You may contact our Privacy Officer or any staff member, including Sherri Alden, Office Manager, at (970) 686-6833.

This notice was published and becomes effective on July 30, 2026, and supersedes the version dated April 1, 2023.

 

HIPAA Consent and Acknowledgement Form

This section is separate from, and in addition to, our Notice of Privacy Practices. Sections 1 and 2 below are required in order to receive care at Althoff Wellness Clinic. Section 3 is required only if you are being evaluated or treated for a spine-related condition. You may decline any of the optional items in Sections 4 through 6 without affecting your ability to receive care.

1. Acknowledgement of Notice of Privacy Practices

I acknowledge that I have been given the opportunity to review Althoff Wellness Clinic's Notice of Privacy Practices. This acknowledgement is required in order to receive care at Althoff Wellness Clinic.

☐  I acknowledge receipt of the Notice of Privacy Practices.

2. General Consent for Treatment, Payment, and Healthcare Operations

I consent to the use and disclosure of my protected health information for the purposes of treatment, payment, and healthcare operations. This consent is required in order to receive care at Althoff Wellness Clinic.

☐  I consent to treatment, payment, and healthcare operations as described.

3. Posture, Range of Motion, and Functional Movement Assessment

For patients being evaluated or treated for spine-related conditions, including sciatica, spinal decompression, and chiropractic care, our providers use an assessment tool that captures photos and video of you on a clinic iPad. This tool uses artificial intelligence to place reference points on your body to assess posture, range of motion, and functional movement as part of your exam. There is not a non-AI alternative available for this specific assessment. These photos and videos are stored as part of your protected health record. Your treating provider reviews and confirms the AI-generated findings before they factor into your exam or care plan. If you are being evaluated or treated for a spine-related condition, this assessment is a required part of how that exam is performed.

☐  I acknowledge that this assessment, including photo and video capture, is used as part of my exam as described above.

4. Documentation Assistance Technology

Althoff Wellness Clinic may use approved software tools during your visit to help our providers accurately capture and document your care. These tools may listen to or record portions of your visit for the sole purpose of assisting with clinical documentation. All documentation produced with the assistance of these tools is reviewed and approved by your provider before it becomes part of your medical record.

☐  I authorize the use of documentation assistance technology during my visits, as described above.

5. Staff Assistance with Documentation and Communications

Our staff may use approved artificial intelligence tools to help draft clinical documentation, patient communications, emails, text messages, and educational materials. Every communication or document is reviewed and approved by a qualified member of our team before it is finalized or sent to you.

☐  I acknowledge that AI-assisted drafting tools may be used to help prepare my documentation and communications, subject to human review.

6. Electronic Communication Authorization

Email — Appointments, Treatment, and Billing

Althoff Wellness Clinic uses a secure, HIPAA-compliant email system to send appointment reminders, treatment information, billing communications, and educational materials tied to your care.

☐  I authorize email communication regarding appointments, treatment, billing, and educational materials related to my care.

Email — Promotional and Marketing

Althoff Wellness Clinic may also send promotional emails, such as clinic offers, seminars, and general educational content not tied to your specific care. Every promotional email includes an unsubscribe option.

☐  I authorize promotional and marketing emails, separate from my appointment, treatment, and billing communications.

Text Messaging — Appointments, Treatment, and Billing

Althoff Wellness Clinic may send text messages for appointment reminders, scheduling, billing notices, and general patient communication related to your care. Message and data rates may apply.

☐  I authorize text message communication regarding appointments, treatment, billing, and general patient communication.

Text Messaging — Educational and Promotional

Althoff Wellness Clinic may also send educational and promotional text messages, typically 4 to 5 per month, most as part of an educational series with occasional one-time promotional messages. You may reply STOP at any time.

☐  I authorize educational and promotional text messages, separate from my appointment, treatment, and billing communications.

You may revoke any authorization above at any time by notifying our Privacy Officer in writing, or, for promotional text messages, by replying STOP.

 

General Examination and Trial Treatment Consent

I understand that today's visit may include an initial or follow-up examination to assess my current condition. This examination may involve movement testing, orthopedic and neurological evaluations, postural assessment, and other procedures appropriate to my symptoms.

For patients with neuropathy or related conditions, the exam may also include checking circulation, balance, and sensory testing to determine what areas can or cannot feel properly.

These evaluations are intended to identify the source of my pain, numbness, or dysfunction and to help determine an appropriate plan of care. I acknowledge that movement or physical testing may temporarily increase my pain or discomfort. This response is generally short-lived and part of the normal evaluation process.

At times, the provider may recommend a short trial or sample treatment using clinic equipment such as SoftWave Therapy or Back on Trac decompression to assess potential benefit. If a trial treatment is performed, I understand that mild soreness, temporary discomfort, or localized irritation may occur. Serious complications are rare but may include bruising, inflammation, or aggravation of pre-existing symptoms.

Certain conditions, such as pregnancy, open wounds, bleeding disorders, or implanted cardiac devices, may require modification or avoidance of specific procedures, and I agree to inform my provider of any known medical conditions before proceeding.

I understand that this evaluation and any trial treatment are for assessment purposes only and do not guarantee future treatment recommendations or outcomes.

 

 

Office Financial Policy

Payment

Payment is expected at the time of your visit. We will accept cash, check, or credit card (excluding American Express). This office may make payment plan arrangements on an individual basis. Any such plan or arrangement will be discussed in your report of findings and must be agreed upon prior to services being rendered.

Nonpayment

As a courtesy, AWC will provide patients with statement(s) of account. If you have not received a statement within 90 days of your appointment, please call us to confirm your billing information. All outstanding balances are due upon receipt and become past due after 30 days.

Late Charge

A late charge of $10.00 (per month) or 8%, per annum, will be applied to all patient balances 60 days overdue, whichever is greater; accounts 90 days past due may be subject to collection action pursuant to the full extent of the law and will continue to accrue interest. Also, be aware that if your account is sent for collection, you may be refused service in the future due to non-compliance.

Financial Responsibility and Confidentiality

You acknowledge your responsibility for all charges incurred during your intake and treatment. In the event of non-payment, you understand that necessary private information may be disclosed to financial or collection agencies to facilitate payment.

If you are referred to another specialist or you discontinue care for any reason, the balance of your account for services previously rendered is due and payable; payment in full is expected immediately, regardless of any insurance claims submitted.

Time-of-Service Discount

If you opt to make full payment for a care plan in order to take advantage of our time-of-service discount, the services will be invoiced at their standard rates until the care plan has been fully executed. Upon successful completion of the care plan, we will reconcile the account, and the applicable discount will then be applied. Please note that if the care plan is not completed as originally intended, the time-of-service discount will not be implemented.

Insurance

All patients are on a cash basis until their respective insurance coverage has been verified by our staff. Expect to pay for the first two office visits to allow staff to verify insurance. We do ask for a copy of your ID card or driver's license due to the many cases of identity theft.

Assignment of Insurance Benefits

I hereby assign, transfer, and set over directly to AWC, sufficient monies and/or benefits for Medpay, medical liability coverage under auto insurance and other health plans to AWC, as applicable to which I may be entitled for professional and medical care, to cover the costs of the care and treatment rendered to myself or my dependent in this Clinic. I authorize the staff of AWC to contact my insurance company or health plan administrator and obtain all pertinent financial information concerning coverage, payments, and deductibles under my policy.

Excluded from Assignment are original Medicare benefits, including Medicare supplements, and Private Health Insurance.

We are a private pay practice. We will bill Medicare, Medicare Supplements, Medpay, and Liability coverage under your auto insurance. For all other insurance carriers, we will provide a superbill for you to turn into your insurance company for reimbursement. We are not a mediator between you and your insurance company and will not enter into any dispute with the same. Please remember that insurance is a contract between you and the insurance company and ultimately the patient is responsible for payment in full. Any denied or disputed claims will be treated as uncovered services, and you will be expected to pay such charges on a timely basis.

Appointment Cancellation and Missed Appointments

If you miss an appointment, that takes away our time and ability to help other patients.

Existing patients of AWC must provide a minimum of 24 hours notice of a canceled, changed, or missed appointment, otherwise charges may be applied at $25 per appointment.

Prepaid new patient appointments likewise require a minimum of 24 hours notice of canceled, changed, or missed appointments, otherwise all collected funds will be retained.

Refunds

All nutritional supplements, equipment, educational curriculum, and professional protocols that you receive with your plan are non-refundable. Once equipment is ordered it is your possession.

Wyoming Right to Cancel a Prepaid Care Plan (Cheyenne location only)

Wyoming chiropractic regulations provide patients the right to cancel a qualifying prepaid care plan (generally, $500 or more collected in advance within a 12-month period) within three business days of entering the plan, without penalty, by submitting written and signed cancellation notice. Once we receive that notice, unused funds are refunded within seven working days. Prepaid funds, including funds paid through financing, are held in a dedicated escrow account until earned. You may request a copy of your escrow account reconciliation at any time. This right does not apply at our Windsor, Colorado location.

If you choose to pay in full for a care plan, you will receive the time-of-service discount only after the care plan has been completed. If you are requesting a refund, the care plan has not been completed and the discount will not be applied. Therefore, you will only be refunded the monies left for the services that were not provided.

Process

When a refund is owed, the recipient may be asked to sign a waiver agreeing to the terms of the refund. Refunds may be processed back to the original payment method or issued via refund check. All refunds can take 7 to 10 business days for processing.

Price Adjustment Clause

AWC may occasionally increase service charges, supply charges, or in some cases pre-paid care plans, should we as a clinic experience inflation of treatment or supply costs exceeding 7%. It is never our intention to increase cost if it can in any manner be avoided.

If you have questions concerning this or any other matter, please speak with the Office Manager prior to seeing the Doctor.

I have read and understand the above Office and Financial Policy and agree to be bound by these terms. I also understand and agree that such terms may be amended by AWC from time to time. This policy amends and supersedes any prior AWC Office Financial Policy.

Patient Consent for Communication with Primary Care Physician

At Althoff Wellness Clinic, we believe in comprehensive care for our patients. As part of our commitment to your health and well-being, we may need to communicate with your primary care physician regarding updates on your treatment and condition. This ensures that all aspects of your healthcare are coordinated effectively.

Consent Statement

I hereby authorize Althoff Wellness Clinic to communicate with my primary care physician regarding updates on my treatment and condition. I understand that this communication is necessary for the coordination of my healthcare and may include information such as treatment plans, progress reports, and diagnostic results.