I acknowledge that everything on this paperwork is filled out accurately and truthfully to the best of my ability. I hereby authorize payment to be made directly to Chiropractic for Kids and Adults, for all benefits which may be payable under a healthcare plan or from any other collateral sources. I authorize utilization of this application, or copies thereof, for the purpose of processing claims and effecting payments, and further acknowledge that this assignment of benefits does not in any way relieve me of payment liability and that I will remain financially responsible to Chiropractic for Kids and Adults for any and all services I receive at this office.
The practice of chiropractic uses spinal and extremity adjustments. This procedure is used to care for patients. The Doctor may use their hands or mechanical instrument upon the patient's body with intent to move their joints. This may cause an audible "pop" or "click" noise and the patient may feel a sense of movement. Your care may also include Analysis, Examination, posture photos and/or X-ray imaging. The purpose of treatment is to help the patient's body function without interference also known as 'subluxations'. By adjusting the body, the doctor is intending to rid the body of subluxations that could cause the patient harm.
Material risks inherent in chiropractic adjustment As with any healthcare procedure, there are certain complications which may arise during chiropractic adjustment and care. These complications could include but are not limited to: fractures, disc injuries, dislocations, muscle strain, cervical myelopathy, caste-vertebral strains and separations. Patients may feel stiffness or soreness following the first few days of corrective care. The Doctor will make every reasonable effort during the examination to screen for contraindications to care; however, if the patient has a condition that would otherwise not come to the Doctor's attention, it is the patient's responsibility to inform the Doctor.
Probability of those risks occurring Fractures are rare occurrences and generally result from underlying weakness of the bone which is checked for during patient history, examination, and may include X-rays. Stroke and/or arterial dissection caused by chiropractic manipulation of the neck has been the subject of ongoing medical research and if there is a causal relationship at all. This is extremely rare and remote.
The availability and nature of other treatment options Other treatment options for patient may include: •Self-administered, over the counter analgesics and rest· Medical care and prescription drugs such as anti-inflammatory, muscle relaxants and painkillers •Hospitalization •Surgery. If the patient chooses to use one of the above noted 'other treatment' options, they should be aware that there are risks and benefits of such options and the patient may wish to discuss these with their primary medical physician. Risks and dangers may also associate with remaining untreated. Remaining untreated may allow the formation of adhesions and reduce mobility. This may set up a pain reaction further reducing mobility and could produce poor health and sickness.
I understand I am responsible for all bills incurred in this office (including, but not limited to late fees, cancellation fees, services not covered by insurance) and that I will be provided a good faith estimate of all service costs for my care if I request it.
(Parents only) CONSENT TO TREATMENT (MINOR) I hereby request and authorize Dr. Evan Crichton to perform diagnostic tests and render chiropractic adjustments and other treatment to my minor child:
This authorization also extends to other doctors and office staff members and is intended to include radiographic examination at the doctor's discretion. As of this date, I have the legal right to select and authorize health care services for the minor child named above. (If applicable) Under the terms and conditions of my divorce, separation or other legal authorization, the consent of a spouse/former spouse or other guardian is not required. If my authority to select and authorize this care should be revoked or modified in any way, I will immediately notify this office.
PLEASE DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE. I have read or have had read to me the above explanation of the chiropractic adjustment and related care. 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 treatment.
Uses And Disclosures of Protected Health Information (Based Upon Written Consent) The patient will be asked by the chiropractor to sign this consent/acknowledgement form. By signing the form, the chiropractic, the office staff and others outside of our office that are involved in the patient's care and treatment (for the purposes of providing health services to the patient) may also use and disclose the patient's protected health information.
Below are examples of the types of uses and discloses of the patient's protected health care information that the chiropractor's office is permitted to make once the patient has signed this consent/acknowledgment form: CHIROPRACTIC CARE: We may use and disclose the patient's protected health information to provide, coordinate, or manage their chiropractic care and any related services. This includes the coordination or management of the patient's chiropractic care with a third party that has obtained the patient's permission to have access to their protected health information. PAYMENT: The patient's protected health information may be used for their chiropractic services. This may include activities that the patient's insurance plan may undertake before it approves/pays for the chiropractic services recommended to them. Those activities may include making a determination of eligibility or coverage for insurance benefits, reviewing services provided to the patient for medical necessity, or undertaking utilization review activities. OTHER USES: The office may: •Call patient by their name in the waiting or adjusting area •Call and remind patient of, reschedule, or cancel an appointment •Leave a message on an answering machine, voicemail or text message •Mail appointment reminders, announcements, or greeting cards to patient's home •Share protected health information with third party entity that perform various activities (e.g. electronic billing, transcription services) for the office· Provide information about treatment alternatives or other health-related benefits and services •Send a newsletter about the practice and services offered to the patient's home. Most office visits are performed in an open area where complete privacy of patient's name and health information will be respected but cannot be guaranteed. Special appointment times can be requested for discussion of any private or confidential matters. The patient's private information may be used when billing insurance claims or collecting an outstanding balance using an outside collection agency. The office will disclose patient's health information to their primary care physician unless specifically requested for the office not to. When an arrangement between the chiropractic office and business associate involves the use or disclosure of the patient's protected health information, a contract will be signed that contains terms that will protect the privacy of their protected health information. Other uses and disclosures of personal health information will be made only with the patient's written authorization, unless otherwise permitted or required by law as described below.EMERGENCIES: The office may use or disclose the patient's protected health information in an emergency treatment situation. COMMUNICATION BARRIERS: Using their professional judgment, the office may use and disclose the patient's protected health information if the chiropractor or office staff member attempts to obtain consent from the patient but is unable to do so due to substantial communication barriers. COMPLAINTS: The patient may complain to the office or to the Secretary of Health and Human Services if they believe their privacy rights have been violated by the office. The patient may file a complaint with the office by notifying the privacy contact of the complaint. The office will not retaliate against the patient for filing a complaint.
The patient may revoke this authorization at any time, in writing, except to the extent that the chiropractor or the practice has taken an action in reliance on the use or disclosure indicated in the authorization.
The patient may have the right to have the chiropractor amend their protected health information. This means the patient may request an amendment of protected health information about them in a designated record set for as long as the office maintains this information. In certain cases, the office may deny the request for amendment. If the amendment request is denied, the patient has the right to file a statement of disagreement with the office. The office may prepare a rebuttal to the patient's statement and will provide a copy of rebuttal if needed. The patient has the right to receive an accounting of certain disclosures of their health information, if any, that the office has made. This right applies to disclosures for purposes other than treatment, payment, or healthcare operations as described in the Notice of Privacy Practices. The patient has the right to obtain a paper copy of this notice from the office, upon request, even if the notice was accepted electronically.
The terms of this Notice may change. If the terms do change, the patient may receive-a revised Notice by contacting the Privacy Contact.
Privacy Contact: Dr. Evan Crichton DC - Chiropractic for Kids and Adults - 3316 Chiquita Blvd S Ste 1 Cape Coral Fl 33914 - 239-800-5197