Terms Of Acceptance
When a patient seeks health care/treatment or health recommendations from The Good News Doctor and accept a patient for such care, it is essential for both to be working towards the same objective.
We have one goal: To support the patient or client in restoring the body to optimal health using an inclusive approach of natural therapies and solutions.
The Good News Doctor may recommend health products, treatment or care beyond what the patient has initially requested because it may support the patient’s body in reaching optimal health.
The patient may decline any recommendation made by The Good News Doctor. The Good News Doctor may share product websites for the patient to learn more about a certain natural solution or therapy.
For more information on the solutions and therapies The Good News Doctor may recommend, visit www.thegoodnewsdr.com.
Financial Arrangements
The Good News Doctor offers conservative fees. We want to make sure that our patients are able to receive the needed care in an affordable manner.
The Good News Doctor does not accept insurance or Medicaid. Payment must be made in the form of cash, check or credit card. In some cases, payment may be required prior to treatment or care.
The Good News Doctor is not liable for any unexpected charges. It is the patient's repsonsibility to ask the doctor about said charges prior to performing scans, procedures, or leaving with product. The patient takes full responsibility for any and all charges billed by The Good News Doctor to the patient.
If your bill remains unpaid after 120 days and no satisfactory payment arrangements have been made towards reconciling it, then the debt on your account may be assigned to a collection agency.
I have read and understand the Terms of Acceptance and Financial Arrangements above and give the doctor permission to evaluate me.
I further agree to the fee schedule set forth by The Good News Doctor and will ultimately be the party that is financially responsible for this account.
Privacy Notice
We recognize and respect the privacy expectations of today’s consumers and the requirements of applicable federal and state privacy laws. We believe that making you aware of how we use your non-public Personal Information, and to whom it is disclosed, will form the basis for a relationship of trust between us and the public that we serve. This Privacy Statement provides that explanation. We reserve the right to change this Privacy Statement from time to time consistent with applicable privacy laws.
In the course of our business, we may collect Personal Information about you from the following sources:
• From applications or other forms we receive from you or your authorized representative;
• From your transactions with or from the services being performed by us, our affiliates or others;
• From our internet websites;
• From the public records maintained by governmental entities that we either obtain directly from those entities or from our affiliates or others; and
• From consumer or other reporting agencies.
OUR POLICIES REGARDING THE PROTECTION OF THE CONFIDENTIALITY AND SECURITY OF YOUR PERSONAL INFORMATION
We maintain physical, electronic and procedural safeguards to protect your Personal Information from unauthorized intrusion. We limit access to the Personal Information only to those employees who need such access in connection with providing products or services to you or for other legitimate business purposes.
OUR POLICIES AND PRACTICES REGARDING THE SHARING OF YOUR PERSONAL INFORMATION
We may share your Personal Information with our affiliates, such as medical doctors, radiologists and/or other chiropractors for the purpose of rendering patient care. We may also disclose your Personal Information as applicable to:
• Your employer as related to Workers’ Compensation injuries, and
• Attorneys as related to personal injury/automobile accident cases.
In addition, we will disclose your Personal Information when you direct or give us permission, when we are required by law to do so, or when we suspect fraudulent or criminal activities. We also may disclose your Personal Information when otherwise permitted by applicable privacy laws, for example, when disclosure is needed to enforce our rights arising out of any agreement, transaction or relationship with you.
RIGHT TO ACCESS YOUR PERSONAL INFORMATION AND ABILITY TO CORRECT ERRORS OR REQUEST CHANGES OR DELETION
You are afforded the right to access your Personal Information and, under certain circumstances, to find out to whom your Personal Information has been disclosed. Also, you are afforded the right to request correction, amendment or deletion of your Personal Information. We reserve the right, where permitted by law, to charge a reasonable fee to cover the costs incurred in responding to such requests. Anyone wishing to obtain a copy of their records must sign a release form. All requests must be made in writing via mail, fax or in person.
Patient Consent Form
FOR USE AND/OR DISCLOSURE OF PROTECTED HEALTH INFORMATION TO CARRY OUT ANALYSIS, TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS.
I, hereby state that by signing this consent and initialing each item, I acknowledge and agree as follows:
1. The practice's Privacy Notice has been provided to me and I have carefully read it prior to my signing this consent.
2. The practice reserves the right to change its privacy practices that are described in its privacy notice, in accordance with applicable law.
3. I understand that, and consent to, the following appointment communications and reminders that will be used by the practice:
• Postcards mailed to the addressee(s) I have provided.
• Telephoning me at the number(s) I have provided and leaving messages for me on my answering
machine or with the individual answering the phone.
• Text messages at the number(s) I have provided.
• E-mail at the email address(s) I have provided.
4. The practice may use and/or disclose my Personal Health Information (PHI) (which includes information about my health or condition, analysis, and the treatment provided to me) in order for the practice to make analyses about my condition(s), treat me, obtain payment for that treatment/care, and as necessary for the practice to conduct its specific health care operations.
5. I understand that I have the right to request that the practice restrict how my PHI is used and/or disclosed except to obtain payment for treatment provided. However, the practice is not required to agree to any restrictions that I have requested, and I have the right to refuse treatment.
6. I understand that this consent is valid as long as I am a patient in this office. I further understand that I have the right to revoke this consent, in writing at any time for all future transactions, with the understanding that any such revocation shall not apply to the extent that the practice has already taken action in reliance on this consent. If I revoke this consent at any time, the practices has the right to refuse to treat me.
7. I give The Good News Doctor permission to treat me in a private room while leaving the door ajar. I am aware that other persons in the office may overhear some of my protected health information during the course of care. Should I need to speak with the doctor at any time in private, the doctor will provide a private room for these conversations.
8. The doctor recommends that a spouse/partner (if applicable) be present at my report of findings visit; therefore I hereby give permission for my protected health information to be disclosed at that time and at any time my spouse/partner contacts the office to check on my status.
I have read and understand the above statements. I understand that I have the right to refuse to sign this authorization. If I choose to decline signing this consent form, this practice will not treat me.