Consent to Bill/Collect Insurance: I consent, if am using a third party for payment of my services (health insurance, auto accident, worker's compensation, Parent/Guardian, etc to allow Complete Care Chiropractic KC to submit all necessary information needed to receive payment for services I received to these third parties. further consent to accept assignment of payments from my insurance company to paid directly to the office.
Consent to Examination and Treatment: - give the doctors and staff of Complete Care Chiropractic KC permission to perform all examinations, x-rays, and treatment deemed necessary by the doctor. lunderstand that some of these procedures may be performed by either the staff or the doctor.
Consent to Retrieve Medical Records: I give the doctors and staff at Complete Care Chiropractic KC permission to obtain all medical records from other providers, offices or hospitals which may assist in my care.
HIPPA: A copy of the full Health Information Privacy Policy for our office can be requested at the front desk. In brief, it states that we will not give any information about you except as consented above. The only people we give information to are your parents/guardian if you are a minor, or whomever is responsible for your bill (i.e. insurance company, third party or attorney if you have one
Clinical Summary Report (CCR): l understand that a clinical summary report is created after each visit for the purpose of EHR and is available for my review. At this time, I am asking Complete Care Chiropractic to save these electronically for me and not print them out after each visit. - understand that, upon request, these reports are available to be printed or emailed to me.