Application for Care- Infant Packet

I have been advised that chiropractic care, like all forms of health care, holds certain risks. While the risks are most often very minimal, in rare cases, complications such as sprain/strain injuries, irritation of a disc condition, and although rare, minor fractures, and possible stroke, which occurs at a rate between one instance per one million to one per two million, have been associated with chiropractic adjustments.  

Treatment objectives as well as the risks associated with chiropractic adjust,ents and, all other procedures provided at Primal Chiropractic have been explained to me to my satisfaction and I have conveyed my understanding of both to the doctor. After careful consideration, I do hereby consent to treatment by any means, method, and or techniques, the doctor deems necessary to treat my condition at any time throughout the entire clinical course of my care. 

This office is required by law, to notify you in writing, we must maintain the privacy and confidentiality of your Personal Health Information. In addition, we must provide you with written notice concerning your rights to gain access to your health information, and the potential circumstances under which, by law, or as dictacted b y our office policy, we are permitted to disclose information about you to a third party without your authorization. Below is a summary of the circumsance, if you would like a more detailed explanation, one will be provided to you. In

Permitted Disclosures: 

1. Treatment purposes: discussion with other health care providers invovled in your care

2. Inadvertent disclosures: open treating area means open discussion. If you need to speak privately to the doctor, please let our staff know so we can place you in a private consulation room. 

3. For payment purposes: to obtain payment from your insurance company or any other collateral source 

4. For workers compensation purposes: to process a claim or aid in investigation 

5. Emergency: in the event of a medical emergency we may notify a family member 

6. For public health and safety: to prevent or lessen a serious or eminent threat to the health of safety of a person or general public 

7. To Government agencies or Law enforcement: to identify or locate a suspect, fugitive, material witness or missing person.

8. For military, national security, prisoner, and government benefits purposes. 

9. Deceased persons- discussion with coroners and medical examiners in the event of a patients death. 

10. Telephone calls or emails and appointment reminders-  we may call your home and leavge a message regarding missed appointments or apprize you of changes in practice hours or upcoming events.

11. Change of ownership- in the event this practice is sold, the new owners would have access to your PHI. 

YOUR RIGHTS: 

1. To receive an accounting of disclosures. 

2. To receieve a paper copy of the comprehensive "Detail" Privacy Notice

3. To request mailings to an address different than residence

4. To request Restrictions on certain uses and disclosures and whith whom we release information to, although we are not required to comply, if however, we agree, the restriction will be in place until written notice of your intent to remove said restriction.

5. To inspect your records and receive one copy of your records at no charge, with notice in advance

6. To request amendments to information. However, like restrictions, we are not required to agree to them. 

7. To obtain ONE copy of your records at no charge, when timely notice is provided (72 hours). X-rays are original records and you are therefore not entitled to them. If you would like us to out source them to an imaging center, to have copies made, we will be happy to accomidate you. However, you will be responsible for the cost. 

COMPLAINTS: If you wish to make a formal complaint about how we handle your health information, please call Benjamin Fehr at (360) 348-8970. If he is unavailable, you can make an appointment with our receptionist to speak with him within 72 hours or 3 work days. If you are still not satisfied with the way this office handles your complaint, you can submit a formal complaint to: DHHS, Office of Civil Rights, 2oo Independence Ave. SW, Room 509F HHH Building, Washington DC 20201. 

 

I have received a copy of Primal Chiropractic's Patient Private Notice. I understand my rights as well as the practicfes duty to protect my hralth information, and havef conveyed my understanding of these rights and duties to the doctor. I further understand that this office has the right to amend this 'Notice of Privacy Practice' at any time in the future, and will make the new provisions effective for all information that it maintains past and present. At this time, I do not have any questions regarding my rights or any of the information I have recieved. 

 

 

At Primal Chiropractic we are committed to providing the very best care for you and/or your family. Part of the process of providing care involves a financial relationship between you, and us, the chiropractic provider. In an effort to make your visit with us simple and smooth, we have provided for you, in advance, our financial policy. Please take time to review our financial policy below. If you have any questions, please ask the front desk team member. 

By providing care for you at this office, all fees must be paid at the time the services are rendered. Payment for our services may be in the form of cash, check, MasterCard, Visa or Discover. We also accept HSA (Health Savings Account) cards. 

For our patients with insurance, we are out of network and it is your responsibility to be familiar with your insurance benefits, both in and out of network. Your insurance plan is a contract between you, your employer, and the insurance company. Although, we are happy to print you super bills for the services you receive at our office. A super bill is an itemized form, detailing services provided to a patient, which you can then submit to your insurance for reimbursement. 

Please understand that we do not have a contract with your insurance company, only you do. We are not responsible for how your insurance company handles its claims or for what benefits they pay you on a claim. We can only assist you in estimating your portion of the cost of treatment. We at no time guarantee what your insurance will or will not do with each claim. Your employer chooses your particular policy and if you are unhappy with its coverage, you should speak with your Human Resources Department. Only your employer can adjust benefits. 

You are responsible for any balance on your account after 30 days. Any account balance exceeding 90 days in age may be forwarded to a collection agency/or attorney. All costs in collecting unpaid fees will be charged to your account. These fees often exceed 50% of the unpaid balance. 

You are responsible for payment for your care. 

In the case extra adjustments are needed outside of your recommended frequency, you will be charged an adjustment fee the day the service is rendered. Please be prepared to pay this fee on the day of service.

The doctor’s care recommendations are based upon what they believe is in the best interest of your well being and health, rather than on what your insurance will cover. 

A $35.00 fee will be assessed for any “returned check.”

No call/No shows will be subjected to a $25 fee. 

I have read the above financial policy and understand my financial options and obligations as described. 

• Appointment Scheduling: We ask that you pre-schedule your future appointments. To keep you progressing in your care, rescheduled appointments ideally should be made up within one week. By pre-scheduling your appointments, this will help you get the time & day that you need. We do require you to have an appointment scheduled before coming in (this is so we can guarantee there is time in our schedule to see you!) No Call No Show appointments will be charged a $25 fee (unforeseen circumstances will warrant an exception, just keep us updated.) Please call or text at least 1 hour before your scheduled appointment to avoid this charge. 
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  Children & Family Wellness: We offer family care and wellness plans at a discounted rate. If your family members have not had their spines/nervous systems checked, we are happy to get them scheduled. Our doctors specialize in children of all ages, and have completed additional courses and certifications in family wellness. Getting kids' nervous systems checked and adjusted, helps with ear infections, colic, allergies, asthma, ADD/ADHD, sensory disorders, digestive difficulties, immune system function, athletic performance, and overall wellness. 
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  Pet Policy: Although we love all furry friends, we do ask that you leave them at home, since Bruce is here, our loving office pup. Service animals are allowed. 
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  Solicitation: We kindly ask that you do not solicit, goods or services to our patients or staff. 
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  Guarantees: We do not guarantee that we can prevent or cure any illness, injury, or disease. Our doctors are trained to detect and remove spinal subluxations in order to allow your nervous system to function with ease, and help reduce the risk of spinal degeneration. 
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  Photography Release: We love taking photos/videos in our office for our social media platforms. By initialing here, you authorize Primal Chiropractic, LLC, and those acting under its permission to copyright, use, and publish the video/photo/audio taken in our office. In the event that the photos/videos participant is a minor, his or her parent or guardian has read and authorized this release on their behalf. We will always ask your permission before taking pictures/videos. 
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  Guest Speaker: Our doctors are available to come to your work, or social events to educate employees/friends on several health topics- managing stress , hormone regulation, nutrition, health essentials, pediatrics, to name a couple! We provide a free health lunch to everyone attending. This is a free lunch and learn we provide, we just ask there to be at least 5 people in attendance.