Whole Body Chiropractic
Policies and Terms of Agreement
Insurance Acknowledgment and Agreement
I understand a Whole Body Chiropractic staff member will verify my insurance eligibility and benefits on my behalf. I acknowledge that the coverage and benefits quoted are terms defined by the policy I hold. I further acknowledge, my insurance carrier's quote of my policy coverage and benefits is not a guarantee of payment.
I agree, I may be held financially responsible to pay for denied "Covered" services, not to exceed my carriers allowed amount per service.
I agree I am financially responsible to pay for any "Non-Covered" services I receive.
With my signature, I consent to the financial responsibilities listed above, and the release of medical records to my insurance company for the purpose of processing claims.
HIPAA Privacy Practices
I acknowledge that I have received and / or have been given the opportunity to review Whole Body Chiropractic's Notice of HIPPA Privacy Policies for protected health information.
X-Ray Consent
By my signature below I understand the hazardous effects of ionization to an unborn child, and I have conveyed my understanding of the risks associated with exposure to x-rays. After careful consideration I therefore, do hereby consent to have the diagnostic x-ray examination the doctor has deemed necessary in my case.
Acknowledgement of Special Promotion X-Rays
In the absence of insurance coverage, if I receive any X-Rays at a discounted or promotional rate, I understand my X-Rays are the property of Whole Body Chiropractic. In the event I wish to receive a copy of my X-Rays, for personal use or for any other doctor, hospital, person or institution, I understand I am responsible to pay the full and customary fee per X-Ray.
Medical Records Release
I hereby give this office permission to share my medical information and records with my primary care physician or specialist if requested. I also give my permission to Whole Body Chiropractic to request and receive my medical records from my primary care physician or specialist.
Tardy / No Show-No Call Missed Appointment Policy
If you are unable to keep your scheduled appointment, it is important you make every reasonable attempt to notify the office, via phone, text, or voicemail, 24 hours prior to the scheduled appointment time.
If you are more than 5 minutes tardy for a scheduled massage, decompression, laser, X-Ray, or Progress Review, your services will be rescheduled to another day.
After the 2nd No-Show-No-Call, and/or Tardy for an appointment, there will be a $50 administrative fee charged to your account.
Unforeseen events, or emergencies will be considered on a case-by-case basis.
Signature
My signature belows represents my acknowledgment, and agreement to all the terms of the policies outlined above. I understand I will not be provided future notifications of the policies above unless I make a specific request in writing.