REGISTRATION FORM

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to Breakthrough Chiropractic Clinic, P.A. I understand that I am financially responsible for any balance. I also authorize Breakthrough Chiropractic Clinic, P.A. or insurance company to release any information required to process my claims.

The patient understands and agrees to allow this

By Using the key below, indicate on the body diagram where you are experiencing the following symptoms:

N=Numbness,   B=Burning,   S=Stabbing,   T=Tingling,   A=Dull Ache

The patient understands and agrees to allow this chiropractic office to use their Patient Health Information for treatment, payment, healthcare operations, and coordination of care. We want you to know how your Patient Health Information is going to be used in this office and your rights concerning those records. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent.  If there is anyone you do not want to receive your medical records, please inform our office.

Chiropractic care focuses on the integrity of your nervous system, which controls and regulates your entire body. Please check beside any condition that you have had or currently have. If you have any questions about this, please ask one of the staff members to assist you.

Our recommendations are based on a desire to see you get well and stay well.  Chiropractic care is covered under many insurance plans.  Most of our patients that have health or accident insurance will fall under one of the plans discussed in this policy.  Regardless of your coverage, we’ll suggest the chiropractic care we think you need.  We ask that you read and understand our policy as it applies to your situation.

PATIENTS WITHOUT INSURANCE (Self-Pay)

We request that 100% of the first visit be paid at the time of the visit unless payment arrangements are made in advance with the office manager. We are happy to accept your cash, check, debit card, or credit card. Patients who pay at the time of service are eligible to receive time-of-service discount.

GROUP OR INDIVIDUAL INSURANCE

Your insurance is an agreement between you and your insurance company, not between your insurance company and our office. We cannot be certain if your insurance covers Chiropractic, although most policies do provide coverage.  The amount they pay varies from one policy to another. When possible, we will verify your chiropractic coverage benefits on your insurance; however, the benefits quoted to us by your insurance company are not a guarantee of payment. As a courtesy to you, our office will file your insurance. It is to be understood and agreed that any services rendered are charged to you directly and you are personally responsible for payment of any non-covered services, deductibles, or co-pays. 

“ON THE JOB” INJURY (Worker’s Compensation)

If you are injured on the job, your care should be paid for under your employer’s Worker’s Compensation insurance.  You must be given authorization by the Worker’s Compensation Adjuster to receive care at our office. According to the authorization provided by the Worker’s Compensation Adjuster, will be the allowed care provided. If we do not receive authorization, you will be fully responsible for services at each visit.

PERSONAL INJURY OR MOTOR VEHICLE COLLISIONS

Please present your auto insurance card, your health insurance card, and tell us if you have retained an attorney.  There are four options available to the PI patient:

Pay cash for your care and we can provide you with statements to submit to the carrier.
Use your Med Pay Benefits of your auto insurance if you have that coverage. 
We will accept a Letter of Protection or Doctor’s Lien from an attorney and await payment at the time of settlement while you are under active care.
Use your own Health Insurance. If using your own health insurance, you will be subject to pay any copays or deductibles that may apply.
Although you are ultimately responsible for your bill, we will wait for settlement of your claim for up to (6) months after your care is completed.  Once the claim is settled or if you suspend or terminate care, any fees for services are due immediately.

NOTE: If you choose to not use your Health Insurance at the start of care, you cannot go back later and request us to file your Health Insurance. Most all Health Insurance Companies require timely filing which doesn’t allow our office to go back and bill your Health Insurance if not billed within their timely filing guidelines.

MEDICARE

We do accept assignment from Medicare.  The check is usually sent directly to our office in payment of the services that Medicare will cover manual manipulation of the spine by a chiropractor to correct vertebral subluxation for Active Treatment (Acute Subluxation or Acute Exacerbation). A patient’s condition is considered Acute when the patient is being treated for a new injury. Acute Exacerbation is a temporary but marked deterioration of the patient’s condition that is causing significant interference with activities of daily living due to an acute flare-up of the previously treated condition. Medicare pays 80% of the allowable fee once the deductible has been met.  You are required to pay the deductible and the remaining 20%. Medicare doesn’t cover Maintenance Care (Support Chiropractic Care). Maintenance Care is that which seeks to prevent disease, promote health, and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3A). Medicare doesn't cover other services or tests a chiropractor orders, including examination(s), x-ray(s), ultrasound therapy, manual therapies, nutritional supplements, or orthotic devices. All these other services we provide are Not Covered by Medicare.  Medicare patients are fully responsible for charges of non-covered services. 

Chronic subluxation - A patient’s condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as is the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further chiropractic treatment is considered maintenance therapy and is not covered. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3).

Secondary insurance may or may not pay for these non-covered services.  Our office completes and files the forms for Medicare at no charge. 

SECONDARY INSURANCE

Please inform us of any secondary insurance you may have.  We will assist you if you need help in filing.

MEDICAID

We do accept assignment from Medicaid for patients 13-years-old and older as long as their Medicaid covers chiropractic care.  Medicaid will cover chiropractic manipulation of the spine. Medicaid coverage may vary from one individual to another, and our office will try and verify your specific Medicaid allowed chiropractic coverage. Medicaid may allow for one set of x-rays per year. There are some individuals that their Medicaid coverage may cover the initial examination. Our office will try and verify to see if your Medicaid may cover the initial exam and if your coverage doesn’t allow for the initial exam, you will be fully responsible for the cost. Generally, Medicaid does not cover the initial examination or any further re-examinations. Medicaid will cover one set of x-rays per year.  You are required to pay your co-pay each visit.  All other services we provide are non-covered.  These services include, but are not limited to, x-rays, examinations, therapies, orthotics, supports, and/or nutritional supplements.  Medicaid patients are fully responsible for charges of non-covered services. If Medicaid requires you to have a referral to our office by your primary care provider for Medicaid to cover your chiropractic care, you are responsible for getting that referral.    

NC MEDICAID MANAGED CARE

All NC Medicaid Managed Care plans offer the same basic benefits and services while some offer added services. If you have one of these NC Medicaid Managed Care Plans, we will have to verify your chiropractic benefits and coverage and we would also have to verify your specific plan has our office listed as contracted provider as they vary from plan to plan. These plans may include Alliance Health, AmeriHealth Caritas, Carolina Complete Health, Healthy Blue, Partners Health Management, UnitedHealthcare Community Plan, WellCare, etc.

NOTE: We will have to have authorization for treatment prior to starting treatment.

MANAGED CARE PLANS

We are preferred providers for Blue Cross / Blue Shield, Cigna, United Healthcare, etc… You are required to pay your co-pay at the time of service.  You are responsible for getting your own referral if one is needed.  Out-of-network benefits are available if a referral is not obtained.

FLEX PLANS/MEDICAL SAVINGS ACCOUNTS

Please inform us if you have a medical savings account, sometimes known as a 'flex plan'.  We will be happy to provide you with a statement of your charges for reimbursement.

I have read the above information. 

To the patient: Please read this entire document prior to signing it. It is important that you understand the information contained in this document. If anything is unclear, please ask questions before you sign.

The nature of the chiropractic adjustment

The primary treatment I use as a Doctor of Chiropractic is spinal manipulative therapy. I will use that procedure to treat you. I may use my hands or a mechanical instrument upon your body in such a way as to move your joints. That may cause an audible “pop” or “click,” much as you have experienced when you “crack” your knuckles. You may feel a sense of movement.

Analysis / Examination / Treatment

As a part of the analysis, examination, and treatment, you are consenting to the following procedures:

❑ Chiropractic Spinal Manipulation   

The material risks inherent in chiropractic adjustment.

As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation and therapy. These complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, cervical myelopathy, costovertebral strains and separations, and burns. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. Some patients will feel some stiffness and soreness following the first few days of treatment. I will make every reasonable effort during the examination to screen for contraindications to care; however, if you have a condition that would otherwise not come to my attention, it is your responsibility to inform me.

The probability of those risks occurring.

Fractures are rare occurrences and generally result from some underlying weakness of the bone which I check for during the taking of your history and during examination and X-ray. Stroke has been the subject of tremendous disagreement. The incidences of stroke are exceedingly rare and are estimated to occur between one in one million and one in five million cervical adjustments. The other complications are also generally described as rare.

The availability and nature of other treatment options

Other treatment options for your condition may include:

• Self-administered, over-the-counter analgesics and rest
• Medical care and prescription drugs such as anti-inflammatory, muscle relaxants and pain-killers
• Hospitalization
• Surgery

If you chose to use one of the above noted “other treatment” options, you should be aware that there are risks and benefits of such options and you may wish to discuss these with your primary care provider.

The risks and dangers attendant to remaining untreated.

Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed.

DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE.

the above explanation of the chiropractic adjustment and related treatment. I have discussed it with the chiropractor and have had my questions answered to my satisfaction. By signing below, I state that I have weighed the risks involved in undergoing treatment and have decided that it is in my best interest to undergo the treatment recommended. Having been informed of the risks, I hereby give my consent to that treatment.