Person(s) to contact in case of emergency, questions concerning my treatment, and any questions concerning any account or account balance.

Our office has a 24 hour Cancellation policy. We do require a Credit Card on file to hold your appointment spot. A $55 fee will be charged if the appointment is not canceled at least 24 hours prior.

If not policy holder please fill out next section.

I acknowledge that the information listed above is true to my knowledge and if there are any changes, I understand that it is my responsibility to contact the office.

LEGAL  ASSIGNMENT OF  BENEFITS  AND   RELEASE OF MEDICAL  AND  PLAN  DOCUMENTS

            In considering the amount of medical expenses to be incurred, I, the undersigned, have insurance and/or employee health care benefits coverage with the above captioned, and hereby assign and convey directly to Powell Chiropractic Clinic all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for services rendered from such doctor and clinic. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize the doctor to release all medical information necessary to process this claim. I hereby authorize any plan administrator or fiduciary, insurer and my attorney to release to such doctor and clinic any and all plan documents, insurance policy and/or settlement information upon written request from such doctor and clinic in order to claim such medical benefits, reimbursement or any applicable remedies.  I authorize the use of this signature on all my insurance and/or employee health benefits claim submissions.

            I hereby convey to the above named doctor and clinic to the full extent permissible under the law and under the any applicable insurance policies and/or employee health care plan any claim, chose in action, or other right I may have to such insurance and/or employee health care benefits coverage under any applicable insurance policies and/or employee health care plan with respect to medical expenses incurred as a result of the medical services I received from the above named doctor and clinic and to the extent permissible under the law to claim such medical benefits, insurance reimbursement and any applicable remedies. Further, in response to any reasonable request for cooperation, I agree to cooperate with such doctor and clinic in any attempts by such doctor and clinic to pursue such claim, chose in action or right against my insurers and/or employee health care plan, including, if necessary, bring suit with such doctor and clinic against such insurers and/or employee health care plan in my name but at such doctor and clinic's expenses.

            Should this assignment be prohibited in part or in whole under any anti-assignment provision of my policy/plan, please advise and disclose to my provider in writing such anti-assignment provision within 30 days upon receipt of my assignment, otherwise this assignment should be reasonably expected to be effective and such anti-assignment is waived.

This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original.  I have read and fully understand this agreement.

 

PRACTICE’S REQUIREMENTS HIPPA

(a)     Is required by federal law to maintain the privacy of your Personal Health Information (PHI) and to provide you with this Privacy Notice detailing the Practice’s legal duties and privacy practices with respect to your PHI.

(b)     Powell Chiropractic Clinic, Inc. adheres to Ohio law in those instances where Ohio law does not conflict with Federal law.

(c)     Is required to abide by the terms of this Privacy Notice.

(d)     Reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice provisions effective for all of your PHI that it maintains.

(e)     Will distribute any revised Privacy Notice to you prior to implementation.

(f)      Will not retaliate against you for filing a complaint.

EFFECTIVE DATE

This Notice is in effect as of 1/1/2019.  If you would like to review our HIPPA agreement, please advise our staff and we will supply you with detailed information.

PATIENT ACKNOWLEDGEMENT

By signing below, I acknowledge that I have read this Notice, and that I understand and agree to its terms

Office Financial Policy

 

It is our office policy that all services rendered are the responsibility of the patient, and that you are ultimately personally responsible for all payments regardless of whether or not this office accepts insurance assignment.

Patients Reasonability:

Deductibles and all co-payments are expected at the time of service, cash patients are required to pay at time of service, unless on a pre-arranged payment plan. Personal balances should not exceed $100 at any time, unless on a pre-arranged payment plan.

It is the policy of this office to extend to our patients the courtesy of assigning your insurance benefits directly to us. We are happy to extend this credit to you so that you can follow through with all of the care you may require. The following are important points of consideration to be aware of:

1.     As a courtesy to you, our office will pre-qualify your insurance coverage, in an effort to help you determine what coverage is available to you under your policy. We will help you make the best estimate of your coverage for the recommended services. This service is a courtesy to you and not a guarantee of payment. As the patient we recommend you to call your insurance company to fully understand your chiropractic benefits. As a courtesy, this office will submit secondary insurance, if necessary.

2.     If your insurance benefits reach a maximum, you agree that any additional care you receive at Powell Chiropractic Clinic will be your financial responsibility.

3.     All patients whose treatment visitation schedule is once per month or longer may not be eligible for insurance assignment as this level of care is rarely covered by insurance. Our office offers wellness plans to allow you to continue needed care.

4.     No one can predict what an insurance company will pay for the usual and customary charges for services rendered. If we participate on your plan, you will not encounter balance billing above the stated fee schedule. If we do not participate, we will work with you to determine the amount of coverage and help estimate your responsibility.

5.     Should you discontinue care for any reason; any and all balances will become due and payable at that time. If you are on a predetermined payment plan, that plan will continue to be in effect until your balance in zero, unless you fail to keep up with your payment plan.

6.     If the patient being treated is a minor, a parent/guardian. For services rendered to minor patients, the parent(s) or guardian(s) of the minor are responsible for payment.

7.     The goal of our office is to provide you with the finest quality chiropractic care available. If you have any questions with regard to your health care or any of our policies, please let us know.