Essential Health and Medicine

Please mark off the areas of your complaint to the diagram below with the following indicators:

PPP = Pain,   NNN= Numbness,   TTT= Tingling,   BBB= Burning,   CCC= Cramping,   XXX= Other

D. Lifestyle:

I have read the above information and certify it to be true and correct to the best of my knowledge, and hereby authorize this office of chiropractic to provide me with chiropractic care, in accordance with this state's statutes. If my insurance will be billed, I authorize payment of medical benefits to Essential Health and Medicine / Dr Donnelly for services performed.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy describes how we may use and disclose your protected health information (PHI) to carry our treatment, payment, or health care operations (TPO) for other purposes that are permitted or required by law. “Protected Health Information” is information about you, including demographic information that may identify you and that related to your past, present, or future physical or mental health or condition and related care services.

Use and Disclosures of Protected Health Information:
Your protected health information may be used and disclosed by your physician, our staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, pay your health care bills, to support the operations of the physician’s practice, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your health care information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations: We may disclose, as needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, marketing, and fundraising activities, and conduction or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

We may use or disclose your protected health information in the following situations without your authorization. These situations included as required by law, public health issues, communicable diseases, health oversight, abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, funeral directors, and organ donation. Required uses and disclosures under the law, we must make disclosures to you when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.

OTHER PERMITTED AND REQUIRED USES AND DISCLOSURES WILL BE MADE ONLY WITH YOUR CONSENT, AUTHORIZATION OR OPPORTUNITY TO OBJECT UNLESS REQUIRED BY LAW.

You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Your insurance policy is an agreement between you and the insurance company. It is important that you understand your health and accident benefits listed in your policy. You or your guardian(s) are personally responsible for any charges for services which are rendered to your account. There are many variations in the HMO’s and PPO’s of today. We request that you call your insurance company to get your Chiropractic Benefits within the first week of care.

As a courtesy to you, our office will also call your insurance company to verify insurance coverage, BUT this is not a guarantee of what the insurance company will pay. We will try, to our best ability,  to ESTIMATE what your co-insurance/co-pay will be at each visit. It is our Office Policy to collect any deductibles, co-insurance, or co-pays at each visit unless other arrangements are made.

ONCE NOTIFIED BY THE INSURANCE COMPANY THAT SERVICES RENDERED ARE NOT PAYABLE UNDER THE “MEDICAL NECESSITY” CLAUSE IN YOUR CONTRACT, YOU AGREE TO ACCEPT FULL RESPONSIBILITY FOR SERVICES RENDERED.

Any overpayment made by your insurance company on your account will be refunded. Any balance not paid by the insurance company ultimately becomes your responsibility. If care is terminated by the patient or the doctor, payment for services is due in full immediately.
In signing this form, I acknowledge that I have read and understand this information.

I request payment of authorized medical benefits be made on my behalf to Dr. Gregory Donnelly, D. C. for any services furnished to me by the list provider/supplier. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable to related services.

I understand that my signature requests that payments be made and authorized release of medical information necessary to pay the claim. If “other health insurance” is indicated in Item 9 of HCFC-1500 form or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the provider or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, co-insurance/co pay, and the non-covered services. Coinsurance and deductible are based upon the charge determination of the Medicare or other insurance carrier.

I authorize the release of any medical or other information necessary to process this claim. I also request payment of government and/or other carrier benefits to the party who accepts assignment of benefits. I authorize payment of medical benefits to the undersigned physician or supplier for services described in submitted claims.