INFORMED CONSENT TO TREATMENT

To the patient, parent, or legal guardian:

Please read this entire form carefully before signing. It is important that you understand the information provided. If you have any questions or concerns, please ask before signing.

Physical Examination and Treatment Plan
A physical examination will be conducted to assess your current level of function and help determine an appropriate treatment plan. This exam may include posture analysis, X-rays, diagnostic ultrasound, range of motion tests, muscle strength tests, and neurological or orthopedic evaluations. Additional testing may also be performed as needed. X-rays (radiology) allow us to see inside the body and provide information not available through physical examination alone. Referrals to other healthcare providers may be made when necessary.

Expected Outcomes
Most patients experience good to excellent improvement with physical medicine and complementary therapies. Improvements may be seen in reduced pain, increased flexibility, better range of motion, decreased stiffness, and improved athletic performance. However, individual results may vary based on factors such as age, health history, occupation, and physical condition. No guarantees of specific outcomes can be made.

Risks and Possible Side Effects
Like all forms of healthcare, physical medicine, massage therapy, and acupuncture carry some risks. These may include, but are not limited to, fractures, disc injuries, sprains, and—though rare—strokes.

Understanding and Acknowledgment
I understand that while the providers involved in my care will do their best to inform me of known risks, they may not be able to foresee or explain every possible complication. I trust that the physician(s) will use their best judgment in making treatment decisions based on the information available at the time and with my best interest in mind.

FINANCIAL DISCLOSURE AND AGREEMENT

Clear communication about financial responsibilities helps ensure you receive the best possible care. Please review the following carefully and sign or initial where indicated to acknowledge your understanding and agreement.

Patient Responsibility
I understand that I am financially responsible for all charges related to my care and/or the care of my dependents.

While I may choose to have my insurance benefits assigned to North Portland Wellness Group (NPWG), I remain responsible for any portion not covered by insurance. This includes, but is not limited to, deductibles, co-pays, co-insurance, and other out-of-pocket costs permitted under NPWG’s contracts with insurance carriers.

Insurance Non-Covered Services
Certain services may not be covered by your insurance plan. Common reasons include:
The service is deemed not medically necessary under your insurer’s guidelines
The service is not a covered benefit of your specific plan
The service is not billable under NPWG’s agreement with your insurance carrier or managed care entity
Your insurance carrier allows NPWG to bill you directly for non-covered services, provided you are informed in advance and have signed this disclosure.

If all or part of a treatment is not covered or is potentially not covered, I understand and agree that:

I am financially responsible for those services
I will make appropriate payment arrangements with NPWG

Payment Options
We accept multiple forms of payment for your convenience. If you are using insurance, please also select a backup payment method for any services not covered by your plan. In most cases, insurance covers only a portion of the total cost of care.

ACKNOWLEDGMENT AND CONSENT

I understand that North Portland Wellness Group will use and disclose health information about me. I understand that my health information may include information both created and received by North Portland Wellness Group may be in the form of electronic or written records or spoken words, and may include information about my health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, and similar types of health-related information.

I understand and agree that North Portland Wellness Group may use and disclose my health information in order to: 

• Make decisions regarding my care and treatment

• Refer to, consult with, coordinate among, and manage along with other health care providers for my care and treatment 

• Determine my eligibility for health plan or insurance coverage, submit bills, claims and other related information to insurance companies or others who may be responsible to pay for some or all of my health care

• Perform various office, administrative and business functions that support my physician’s efforts to provide me with, arrange and be reimbursed for quality, cost effective health care. 

• Send and receive prescription information electronically and verbally from pharmacies 

I also understand that I have the right to receive and review a written description of how North Portland Wellness Group will handle health information about me. This written description is known as a Notice of Privacy Practices and describes the uses and disclosures of health information, the information practices followed by the employees, staff and other office personnel of North Portland Wellness Group and my rights regarding my health information.

I understand that the Notice of Privacy Practices may be revised from time to time, and that I am entitled to receive a copy of any revised Notice of Privacy Practices.

I also understand that a copy or a summary of the most current version of Portland Wellness Care’s Notice of Privacy Practices is posted in the waiting room/reception area. 

I understand that I have the right to ask that some or all of my health information not be used or disclosed in the manner described in the Notice of Privacy Practices

I understand that North Portland Wellness Group is not required by law to agree to such requests. By signing below, 

I agree that I have reviewed and understood the information above and that I have received a copy of the Notice of Privacy Practice 

CANCELLATION AND NO SHOW POLICY

We require 24 hours’ notice for all appointment cancellations. This helps us keep care available for other patients. You can text us from the number you receive intake forms and appointment reminders or you can call us at 503-893-4407

Medicaid / OHP Patients:
No fees are charged for missed or late-cancelled appointments. After three (3) unexcused missed appointments, you may be removed from the regular schedule and only seen on a walk-in basis, depending on provider availability.

Private Insurance / Self-Pay Patients:
First unexcused no-show or late cancellation: No fee
Second unexcused no-show or late cancellation: $25 fee
Third unexcused no-show or late cancellation: $50 fee

Excused Absences:
Emergencies or unavoidable circumstances may be excused at your clinician’s discretion. Please contact us as soon as possible if this applies.

 

SOBRIETY AND FITNESS FOR CARE

Patients are expected to present for care in a sober, clean, and hygienic condition. The use of, or being under the influence of, alcohol, cannabis, controlled substances, or any medication that impairs cognitive or physical function is strictly prohibited prior to and during treatment. Patients must be physically and mentally fit for care at each visit.

If, in the professional judgment of the provider or clinic staff, a patient appears impaired, intoxicated, malodorous, or otherwise unfit for treatment, services may be declined or terminated to protect patient safety, provider safety, and clinical standards.

Such occurrences will be documented and treated as same-day cancellations, subject to the clinic’s standard cancellation policy. Repeated violations may result in permanent discharge from care at the discretion of the clinic.

Patient Acknowledgment:
I have read and understand the Sobriety and Personal Hygiene Policy. I agree to comply with these requirements as a condition of receiving care at this clinic.