As either the Patient or the legally authorized representative of the patient on behalf of the patient recelving care with Active Family Chiropractic, I make the following consents, understandings, and agreements on my own behalf and on behatf of the Patient, in partal consideration of health care services to be provided to the Patent in the facility:
Consent for Services: I hereby give consent to Active Family Chiropractic to perform Chiropractic adjustments and/or Acupuncture and any other chiropractic procedures, including examination tests, diagnostic x-rays and physical therapy techniques, spinal decompression and /or cold laser therapy on me (or on the patient named for which I am legally responsible) which are recommended as treatment for me. I have the opportunity to discuss with the doctor, my diagnosis, the nature and purpose of chiropractic adfustments and other procedures and alternatives. I understand and lam informed that in the practice of chiropractic there are some risks to exam and treatment, including but not limited to, fracture, disc injuries, strokes, dislocations, spins, and increased symptoms and pain or no improvement of symptoms. I do expect the doctor to exercise judgment during the course of the procedure that the doctor feels at the time, based on the facts then known, is in my best interest. I further acknowledge that no guarantees or assurances have been made to me cancerning the results intended from the treatment.
Release of Information: Active Family Chiropractic is required by law to make and keep records of the Patient's medical treatment. The Chiropractic Physician safeguards those records and uses and discloses such records and the information they contain only in accordance with the State and Federal privacy laws. Such uses and disclosures are described in detail in the Physicians Notice of Privacy, which may be amended from time to time. I understand that the Patient may ask for a copy off the current notice at any time
Assignment of Benefits: Any and all benefits from insurance companies and other third party payers that are payable to the Patient or on behalf of the Patient for health care, services and related payments for services rendered or provided to the Patient are hereby transferred and assigned to the Physician for the exclusive purpose of paying for charges associated with the health care services provided to the Patient by the Physician. I understand and intend that all insurance cornmanies and other third party payers will pay benefits directly to the Physician in payment of the Physician's charges and the charges ofany other health care providers for whom the Physician is authorized to bill in connection with health care services provided to the Patient.
Financial Responsibility: Patient and the undersigned, if other than the Patient, each jointly and severally agree to pay for all the health care services rendered to the Patient by the Physican including but rot limited to any amounts not paid by any insurance company or other third party payer (excluding a contract discount). Patient and the undersigned, if other than the Patient, remain responsible for all co-payments, deductibles, co-insurance, and/or non-covered services regardless of amount paid by insurance or third party payer. I understand and agree that a finance charge of 1.5% per month (annual percentage rate 18%) of the unpaid balance will be added monthly. Should collection become necessary, the responsible party agrees to pay a collection fee of up to 40% and all legal fees of collection with or without suit, including attorney fees and court costs. A service charge of $20.00 may be collected in connection with any check.or other instrument tendered by the Patient or the undersigned but returned unpald to the Physician.
Missed Appointment Policy: A 24-hour notice is required for all cancellations. A $40 fee will be charged for all missed appointments. Your group, auto, or personal insurance will not cover this fee. If the office is closed, please leave a detailed message.
Photo and Testimonial Release: Active Family Chiropractic is proud of the success that our patients experience and like to share our patient's progress with others from time to time via our Facebook page, website and other media. If the opportunity arises we would like to share your photo, success story, and/or testimontal with others to help spread the word about the benefits of chiropractic care and hour we can help the lives of others. Please choose an option below: