Welcome to Accelerated Care Chiropractic

All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent. 

At Accelerated Care Chiropractic, we aim to provide the highest quality care. Part of this care may involve cervical (neck) manipulation. We feel it is important that you are aware that as with any health care procedure there is some risk associated with cervical manipulation. The risk is currently estimated at 1 in 1,000,000 for stroke or stroke like symptoms. This is a rare and unpredictable event. Other risks that can be associated with spinal adjustments include disc injuries, rib fractures, sprains/strains or pre-existing conditions may be aggravated. We take every precaution to ensure that this risk is minimised through thorough testing, examination and the use of gentle and specific techniques. If you have any concerns, please let the chiropractor know.

I hereby request and consent to the performance of Manipulation (adjustments) and other procedures including various modes of physical therapy and diagnostic x-rays, on me (or on the patient named below, for whom I am legally responsible) by the doctor named above. I have had the opportunity to discuss with the doctor and/or with other office or clinic personnel the purpose and benefits of Manipulations(adjustments) and other treatments outlined below. Alternatives to treatment have been reviewed. I understand that I will be receiving one or more of the following treatments: Manipulation/ Mobilization Therapy, Hot/Cold packs, Ultrasound, Myofascial Release, Traction, EMS, Therapeutic exercises, Massage, Graston Technique, and/or Kinesiology Taping. I understand that Manipulation is not an exact science and that, therefore, reputable practitioners cannot fully guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the treatment that I have requested and authorized. I have had the opportunity to read this form and ask questions. My questions have been answered to my satisfaction. I consent to the proposed treatment.

I authorize use of this form on all my insurance submissions. I authorize release of information to all my insurance companies. I understand that I am financially responsible for all charges whether or not paid by the insurance companies. I authorize my doctor to act as my agent in helping me obtain payment from my Insurance Companies. I authorize payment direct to my doctor. I permit a copy of this authorization to be used in place of the original.

First and foremost we would like to thank you for choosing Accelerated Care Chiropractic aka Accelicare as your health care provider. We are committed to your care. The following is a statement of your Financial Policy, which we require you to read carefully and sign prior to any care.

TO ALL PATIENTS:• You ultimately assume all financial responsibility for all goods and services, whether or not an insurance company is involved.

• We accept Cash, Checks, Visa, and Mastercard• Parents or Guardians are responsible for minor’s payment.

TO PATIENTS NOT USING INSURANCE:

1. If You Do Not Have Insurance: All payments are expected at the time of service or by an authorized payment plan. Your personal balance may not exceed $300 at any time or care may be terminated. Our payment plans make care an affordable part of your family budget.

2. TO PATIENTS USING INSURANCE:

• Please be advised that we are “out of network” on all plans and bill your insurance as a courtesy to you.

• It is your responsibility to know your insurance coverage. All deductibles and co-payments are expected at the time of service or by an authorized payment plan. Your co-insurance balance may not exceed $300 or care may be terminated. Our payment plans make care an affordable part of your family budget. You are considered a cash patient until you bring in your completed insurance forms, and we qualify and accept your insurance coverage. We do not accept assignment for secondary insurance carriers but will be happy to provide you with a claim form for your secondary carrier. Our fees are considered usual, reasonable and customary by most companies, and therefore are covered up to the maximum allowance determined by each carrier. This statement does not apply to companies who reimburse based on an arbitrary schedule of fees bearing no relationship to the current standard and of care in this area.  If your carrier has not paid a claim within sixty (60) days of submission, you agree to take an active part in the recovery of your claim.  If your insurance carrier has not paid within ninety (90) days of submission, you accept responsibility for payment in full of anyoutstanding balance and authorize us to use your credit card to collect full payment. Charges for services rendered will be due as theyare rendered. If you discontinue care for any reason other than discharge by the doctor, all balances will become immediately due and payable in full by you, regardless of any claim submitted. We charge the full fee for missed appointments, unless canceled 24 hours in advance. This fee is NOT billed to your insurance company and must be taken care of prior to your next appointment. If you have a credit or debit card on file it will be automatically used for any balances unless otherwise specified.

I have read, understand, and agree to the Financial Policy.