Have you had or do you have these symptoms in the past 6 months?

I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy on me (or on the patient named below for whom I am legally responsible) by Jared Young, D.C. and/or other licensed doctors of chiropractic who now or in the

future work at Peak State Wellness.

I have had an opportunity to discuss with the doctor named above and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and other procedures. I understand that results are not guaranteed. I understand that my treatment plan can include but is not limited to manual therapy, exercise, bracing, and electrical stimulation for pain management.

I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment, including but not limited to fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely upon the doctor to exercise judgement during the course of the procedure which the doctor feels at the time, based on the facts then known to him or her, is in my best interest.

I have read, or had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) of

24 Hour No- Show policy and Fees

Recognizing that everyone's time is valuable and the appointment time is limited, we ask that you provide a 24 hour notice if you are unable to keep your appointment.

Each time a patient misses an appointment without providing proper notice, another patient is prevented from receiving care. So in order to provide quality care and accommodate to all of our patients in a timely manner;

Our No Show Policy is as follows

A 24-hour notice is required to reschedule or cancel your appointment.

Late cancellations are considered a "No Show." Calling at the last minute before your scheduled appointment or leaving a message with the answering service is not acceptable cancellation.

You, NOT your insurance company, will be charged $65.00 for the time slot we were not able to fill when you were a No Show.

By signing below, you acknowledge that you have received this notice and

Our notice of Privacy Practice provides information about how we may use and disclose protected health information about you. The notice contains a Patient Rights Section describing your rights under the law. You have the right to review our Notice before signing this consent as terms of our notice may change. If we change our notice, you may obtain a revised copy by contacting our office. You have the right to request that we restrict how protected health information about you for treatment and health care operations. You have the right to revoke this consent in writing signed by you. However, such a revocation shall not affect any disclosures we

have already made in reliance on your prior consent. The practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPPA The patient understands that: Protected health information may be disclosed or used for treatment, payment, or health care operations. The practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice. The practice reserves the right to change the Notice of Privacy Practices. The patient has the right to restrict the uses of their information but the practice does not have to agree to those restrictions. The patient may revoke this consent in writing at any time and all future disclosures will then cease

The practice may condition receipt of treatment upon the execution of this consent.

Peak State Wellness Billing Policy

your out of pocket expense per treatment session will be $

Peak State Wellness will be billing your insurance for the treatment that you receive under our care. Based on the insurance verification that we've done we estimate that . You will be receiving an Explanation of Benefit that details the amount that has been billed, the amount that your insurance company paid, and an amount that you might be responsible for. We will NOT BE SENDING A BILL for what your insurance company doesn't pay. If after we have received a response from your insurance company we determine that the amount that you have paid is too much we will reimburse you. If the amount that you have paid is

not enough WE WILL NOT BACK BILL YOU. We will let you know from that time forward how much you need to pay.

You will not be billed any amount that you have not agreed to in writing.

Companies that might show up on an Explanation of Benefit that are associated with us include:

Peak State Wellness Jared Young DC East Medical

Monarch Diagnostic West Coast Rehab Pacific Diagnostic Sean Johnston MD Audrey Huang MD Mark Chavez MD TNT Medical Management

Your signature below acknowledges your acceptance and understanding AND authorizes us to share this document with the primary subscriber on your insurance policy, as they will be the ones receiving the EOBs