I have sought the chiropractic and health care services of Balance Medical Integration LLC for my personal healthcare, or for my child or children, who are minors. I understand that this chriopractic office uses some diagnostic and treatment methods that are known as complementary, alternative or holistic and may not be covered by my insurance plan, or generally accepted by mainstream medicine. The terms complimentary, alternative, and holistic refer to therapies that my include, but are not limited to, dietary and nutritional supplement advice and various diagnostic/testing procedures. Furthermore, the information gained from laboratory and evaluation tests may be interpreted differently from mainstream doctors. Approaches for improving general health and nutrition may be based upon the tests/evaluations and philosophies of complementary medicine and may or may not be consistent with mainstream medical tests/evaluations and philosophies.
In addition to recommending oral nutritional supplments, our office may recommend acupuncture, massage and/or exercise therapies. Some of these products/approaches are not FDA approved or evaluated for any disease or condition, and are not considered the standard practice in mainstream medicine.
Our chiropractic and nutritional practice is exclusively an office-based practice. We are not affiliated with a local hospital. As a result, WE STRONGLY RECOMMEND THAT IN ADDITION TO OUR CARE YOU MAINTAIN A RELATIONSHIP WITH ONE OR MORE PHYSICIANS QUALIFIED TO CARE FOR YOUR HEALTH CONDITIONS.
For example, in the case of children, we advise that you seek the advice of a pediatrician; if you have cardiovascular disease, consult with a cardiologist; and if you have cancer, consult with an oncologist, etc. Our office routinely refers patients to these and other health care professionals when it is deemed necessary. These physicians can provide you and your family with emergency care if hospitalization is needed, with ongoing follow-up care. We are happy to cooperate and communicate with your doctor(s) regarding your chiropractic condition(s) treatment options, or any other health related issues.
Our office and its employees make no representations, claims, or guarantees regarding the efficacy of our treatment recommendations. The treatments we recommend are based upon a combination of our clinical experience and knowledge of scientific and chiropractic literature. With this information individualized treatments may be offered and applied either as adjunctive (complementary) or primary treatments for various symptoms and disease states.
By signing this informed consent, you agree to hold Balance Medical Integration LLC including Jason Bojar DC, Jessica Balbo DC and its employees from all professional and personal liability. You agree to be responsible for all legal costs and fees that may result from action(s) on your part or on the part of your representative(s) against us. If a legal case is brought against us, you agree that we shall be judged by the standards and principles of complementary, alternative, and/or holistic medicine and not the standards and principles of consensus conventional medicine. You have the right to have this consent reviewed by your lawyer before accepting any chiropractic and/or nutritional services from this office.
Our office makes availalbe nutritional supplements and other health products. You are in no way obligated to purchase these products from our office or any other specific location or company. You may freely choose to purchase such products from any source(s) as you wish. Balance Medical Integration LLC and its employees may profit from the sale of supplements and other products that we make available to our patients.
Most insurance plans cover services that they consider medically necessary and/or reasonable and customary. Many of our services (such as nutritional consultations, acupuncture, and others) are often not considered by insurance companies to be necessary based upon their own internal criteria. By signing this form, you accept full financial responsibility for all services, including consultations, lab tests and other procedures. In the event that an insurance company would like information from your file to be faxed and/or e-mailed to them by our office staff, a charge of $30 per 15 minutes (time necessary to organize and send information) will be billed to you, the patient. Please tell the doctor if you do not want this information shared.
SIGNATURE ON FILE: I authorize any holder of medical/chiropractic information about me to release to my insurance company and its agents any information needed to determine these benefits or the benefits payable for related services.
Your signature verifies that you have not been told to discontinue treatments with any other medical specialists or other health care providers.
Your signature is being given prior to rendering any services, advice, and/or recommedations whatsoever from Balance Medicial Integration LLC.
It is the responsibility of the patients to follow-up with our office for results of all testing and lab procedures. It should not be assumed on the part of the patient that if they are not contacted by Balance Medical Integration, or its employees, or if the patient does not schedule or keep a consultation, that test results are normal (or without abnormalties), and may not require further medical treatments or advice. Health/medical recommendations and/or possible referral and additional follow-up may be warranted based upon laboratory testing and evaluations.
The patient is further notified that some tests, or all, may not be covered by their insurance company. The patient assumes full responsibility for the costs of non-covered test. Balance Medical Integration LLC does not assume responsibility for costs incurred regarding non-covered and/or potentially covered services, including procedures, lab test and consultations.
PAYMENT REQUIREMENTS
Our office requires that payment be received for services rendered at the time of your visit. Please come prepared to pay for your visit fees with a check, credit card, or cash. Our office cannot maintain a balance-due for services rendered. If paying by check, please bring more than one check since certain laboratory testing fees require separate payment directly to the laboratory. Some or all of your visit fees may be reimbursable to you by your insurance company. Our front desk will provide you with detailed receipts you will need to submit to your insurance company. Balance Medical Integration and it's employees do not guarantee insurance coverage for any laboratory or services rendered. PLEASE NOTE THAT THE SERVICES OFFERED AT BALANCE MEDICAL INTEGRATION ARE NOT COVERED BY MEDICARE OR MEDICAID. All medicare patients will be asked to please sign an Advanced Beneficiary Notice of Non-Coverage (ABN) Form.
By entering your signature below, you are acknowledging that you understand all terms, verbiage (language), and concepts herein.
I understand this consent agreement and have executed it freely and willingly.