• I confirm that all information given in this form is true, complete, and accurate.
• I released this organization for any responsibility in case of accident, illness, or injury.
• I acknowledge that no assurance was offered about the outcome.
• I acknowledge that I received an Informed Consent document and the health staff explained it to me thoroughly.
• ***HIPAA: The HIPAA Privacy Practices of Homan Chiropractic regarding protected health information and Informed Consent are available on our website will be provided at your first visit**

Before this office begins any health care operations we require you to read and sign this form stating that you understand the items below. If you refuse to sign this form the doctor reserves the right to refuse care.

Acknowledgment of Assignment of Benefits:

I understand and agree that health and accident insurance policies are an agreement between an insurance carrier and me. By signing below I hereby authorize the assignment of benefits for services rendered to me to be paid directly to Dr. Homan and/or Homan Chiropractic Inc. by any first-party, second-party and/or third-party carriers (all insurance companies, attorneys, etc I further acknowledge that I am fully responsible for all services rendered. I understand that I may receive a billing statement for services applied to my deductible, co-payments, or any balance due as stated by the insurance company as my responsibility. In the event I receive payment for any services rendered I agree to promptly remit payment within 5 business days to Homan Chiropractic Inc. I understand that I am responsible for collection fees, court costs and reasonable attorney fees to collect unpaid accounts. The return check fee is $30.

X-rays Studies: I give consent to Homan Chiropractic Newport. to perform x-rays as deemed necessary, declare to the best of my knowledge that I am not pregnant (or my child is not pregnant) and have no known limitations or contraindications for x-ray evaluation. I understand that in the event x-rays are taken that the services of a qualified radiologist from Diagnostic Imaging Inc. may be utilized for a second opinion or further interpret my x-rays and give consent for their release.

Acknowledgment of Notice of Privacy Practices: We are very concerned with protecting your personal health information. There may be times our office may need to contact you regarding office matters. By signing below you have authorized this office to contact you for office related matters in the following manner: phone-work-home or mobile, e-mail and regular mail. Messages may be left on an answering device/voicemail, or with the person answering your phone. Also in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), updated September 23, 2013, this office is obliged to supply you with a copy of the office privacy policies and procedures upon request. This document outlines the use and limitations of the disclosure of your personal health information and your rights as a patient. By signing below you have acknowledged that you have been offered a copy of this document.

CMS-1500 Health Insurance Claim Form: By signing below I acknowledge and agree that the CMS-1500 Health Insurance Claim Form Box 12 and Box 13 will state "Signature on File." Box 12 reads as follows: "Patient's or Authorized Person's Signature - I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below." Box 13 reads as follows: "Insured's or Authorized Person's Signature - I authorize payment of medical benefits to the undersigned physician or supplier for services described below."

Written Consent: Appointment of Representation By signing this form I am providing written consent allowing this provider to act on my behalf as my representative in order to (1) obtain insurance coverage and/or benefit information (deductible, amount of deductible met, copay, co- insurance, insurance limitations, etc; (2) request and/or perform an appeal/review/reconsideration to an insurance company; (3) prepare or complete any necessary forms to obtain prior authorizations, precertifications, referrals and/or payment; (4) initiate a complaint to the Insurance Commissioner for any reason on my behalf.

Acknowledgement: By signing below I acknowledge that I understand and agree with the policies and procedures outlined in this Terms of Acceptance form. By signing below I acknowledge and certify that all the information given to the office/ provider in the INTAKE forms are true and accurate to the best of my knowledge.

Informed Consent for Chiropractic Services

By reading below I have been made aware:

1. That the process of delivering a "Chiropractic Adjustment/Manipulation" may be performed manually, with a table mechanism, or with an instrument to the vertebra(e) of the spine and/or associated structures (arms, legs, etc, often resulting in an audible pop or click sound; 2. As an addition to the Chiropractic Adjustment "Supportive Therapies and/or Adjunctive Modalities" may be applied by the chiropractor or by staff under the chiropractor's direction or supervision incorporating the use of electricity, traction, motion, nutritional advice, heat or cold; 3. That on occasion some temporary soreness and/or stiffness may occur; less frequently aggravation of presenting symptoms or initiation of new symptoms; rarely bruising, swelling, even more rare separation/fracture, and extremely rare, nerve or vascular injury, including stroke, may occur in conjunction with the process of a Chiropractic Adjustment; 4. That the chiropractor has made no guarantee of a positive outcome from treatment; 5. That I have been afforded ample opportunity for questions and answers; and 6. That the above risks of the treatment procedures, options, and financial obligations have been explained to me.

I consent to the performance of diagnostic and therapeutic procedures deemed reasonable and necessary by the doctor and/or staff under the direction and supervision of the office chiropractor(s) involved in my case.

Chiropractic is a system of health care delivery, and therefore, as with any health care delivery system we cannot promise a cure for any symptom, disease or condition as a result of treatment in this office. We will always give you our best care. We work with numerous health care providers and will make the appropriate referral when necessary. If you have any questions on the above items, please ask the doctor. When you have a full understanding, please sign and date below.

It is my choice to receive massage therapy. I am aware of the benefits and risks of massage and give my consent for massage. I understand that there is no implied or stated guarantee for success of effectiveness of individual techniques or series of appointments. I acknowledge that massage therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitiones of any changes in my health status.

I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. I understand and consent that my medical information may be shared by the various care providers involved im my care and treatment.

Treatments may be covered by extended health care plans. I understand that it is my responsibility to confirm the exact details of my coverage.