I hereby request and consent to the performance of medical therapies, rehabilitation exercises, and chiropractic manipulation as well as manual therapy techniques and other chiropractic procedures, including various modes of physical therapeutic modalities and procedures and diagnostic X-rays, where warranted, on me (or on the patient named below, for whom I am legally responsible) by Advance Nurse Practitioner and the Doctor of Chiropractic respectively as employed  by Quality of Life Medical Center. This will cover consent for any other licensed Medical Professionals who now or in the future, work at the clinic of Quality of Life Medical Center.

I understand that I will have an opportunity to discuss with the Advance Nurse Practitioner and Doctor of Chiropractic in this office, the nature and purpose of all services recommended including medical therapies, rehabilitation exercise therapies, chiropractic adjustments and other procedures. I understand that results are not guaranteed.

I understand and I am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment and diagnostic services including but not limited to: 

Manipulation: increased pain or discomfort, fractures, disc injuries, strokes, dislocations, and sprains. 

Rehabilitation exercise therapeutic modalities and procedures: additional pain and discomfort. Endurance exercise may cause increased risk of acute Myocardial Infarction (heart attack) in patients with known or possible cardiac conditions. 

Radiographs: ionizing radiation can be harmful to a fetus for those who are pregnant or might be pregnant.

Medical Therapies: allergic reaction, bruising, infection, scars, bleeding, dizziness and in rare circumstances, possible collapse of lung, cardiovascular and/or cerebral problems.

I do not expect the Advance Nurse Practitioner or the Doctor of Chiropractic to be able to anticipate and explain all risks and complications, and I wish to rely upon the Medical Team to exercise judgment during the course of the procedure which the Medical Team feels at the time, based upon the facts then known to him or her, is in my best interest. The Medical Team of this clinic has additionally explained the risks associated with my refusal of treatment.

I have read, or have had read to me, the above consent. I understand that I will have an opportunity to ask questions about its content prior to services being done, and by signing below I agree to the abovenamed procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

Please be informed that HIPAA or Health Insurance Portability and Accountability Act provides safeguards to protect your privacy.

A more complete text of HIPAA policy is posted in the office at the Front Desk (see binder)

WHAT THIS IS ALL ABOUT:
Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. 


HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. 


Additional information is available from the U.S. Department of Health and Human Services. (www.hhs.gov) The undersigned does hereby acknowledge that he or she has received a copy of this office’s Notice of Privacy Practices Pursuant to HIPAA and has been advised that a full copy of this office’s HIPAA Compliance Manual is available upon request. 


Further I allow this office to send text and email reminders to my personal email and cell phone regarding care or notices of the office. I can opt out at any time. 


The undersign does hereby consent to the use of his or her health information in a manner consistent with the Notice of Privacy Practices Pursuant to HIPAA, the HIPAA Compliance Manual, State law and Federal Law.

• Patients/Clients have the right to be treated with dignity and respect.
• Patients/Clients have the right to fair treatment, regardless of race, ethnicity, creed, religious belief, sexual orientation, gender, age, health status, or source of payment for care.
• Patients/Clients have the right to have their treatment and other patient information kept private. Only by law may records be released without patient permission.
• Patients/Clients have the right to access care easily and in a timely fashion.
• Patients/Clients have the right to a candid discussion about all their treatment choices, regardless of cost or coverage by their benefit plan.
• Patients/Clients have the right to share in developing their plan of care.
• Patients/Clients have the right to the delivery of services in a culturally competent manner.
• Patients/Clients have the right to information about the organization, its providers, services, and role in the treatment process.
• Patients/Clients have the right to information about provider work history and training.
• Patients/Clients have the right to information about clinical guidelines used in providing and managing their care.
• Patients/Clients have a right to know about advocacy and community groups and prevention services.
• Patients/Clients have a right to freely file a complaint, grievance, or appeal, and to learn how to do so.
• Patients/Clients have the right to know about laws that relate to their rights and responsibilities.
• Patients/Clients have the right to know of their rights and responsibilities in the treatment process, and to make recommendations regarding the organization’s rights and responsibilities policy.

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• Patients/Clients have the responsibility to treat those giving them care with dignity and respect.
• Patients/Clients have the responsibility to give providers the information they need, in order to provide the best possible care.
• Patients/Clients have the responsibility to ask their providers questions about their care.
• Patients/Clients have the responsibility to help develop and follow the agreed-upon treatment plans for their care, including the agreed-upon medication plan.
• Patients/Clients have the responsibility to let their provider know when the treatment plan no longer works for them.
• Patients/Clients have the responsibility to tell their provider about medication changes, including medications given to them by others.
• Patients/Clients have the responsibility to keep their appointments. Patients should call their providers as soon as possible if they need to cancel visits.
• Patients/Clients have the responsibility to let their provider know about their insurance coverage, and any changes to it.
• Patients/Clients have the responsibility to let their provider know about problems with paying fees.
• Patients/Clients have the responsibility not to take actions that could harm others.
• Patients/Clients have the responsibility to report fraud and abuse.
• Patients/Clients have the responsibility to openly report concerns about quality of care.
• Patients/Clients have the responsibility to let their provider know about any changes to their contact information (name, address, phone, etc).
• Patients/Clients have the right and the responsibility to understand and help develop plans and goals to improve their health.

I have read and understood my rights and responsibilities.

Our recommendations at Quality of Life Medical Center (QMC) are based on a desire to see you get well and stay well. Healthcare 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 will suggest the treatment we know you will need. We ask that you read and understand our policy as it applies to your situation.

*PATIENTS WITHOUT INSURANCE (SELF PAY)
We request that all services are prepaid for care plan. Care must be paid at time of service if unable to pay full treatment plan.
*We accept Cash
*We accept Personal Check ($30 Fee for Returned Check).
*We accept MasterCard, Discover, and Visa, American Express

• For convenience we can store credit card on file securely to allow for speed of checkout and payment plans.

*We accept Care Credit Card and other financial solutions to help with medical expenses.
*We accept HSA and FSA cards. (please know your balance on the card)

*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 care in our office, although most policies do provide coverage. The amount they pay varies from one policy to another. When possible, we will call to verify 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 complete any necessary insurance forms at no additional charge, and file them with your insurance company to help you collect. 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.

*MANAGED CARE PLANS (PPO/HMO)

• *If your policy is an HMO, a Primary Care Provider (PCP) referral is required to have care in our office**
• We strive to be IN NETWORK providers. Please understand, every medical professional in our practice has different insurance contracts or has opted out of network for the following major companies for various reasons: We will let you know if your Medical Provider is covered by your plan.
• You can receive a SUPER BILL statement that allows you to bill your insurance for out of network benefits.
• Most covered plans in our office at this time are: Ambetter, Devoted, Medicare part B, Medicare Replacement plans, Blue Cross Blue Shield, UMR, and United Healthcare.
• At any time we may have to leave an insurance company contract and patients with that plan will be notified 30 days prior and may be able to be used for up to 90 days post according to insurance carrier policy

*FLEX PLANS/MEDICAL SAVINGS ACCOUNTS
Please inform us if you have a medical savings account (HSA), sometimes known as a 'flex plan'. We will be happy to provide you with a statement of your charges for reimbursement.

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

*PERSONAL INJURY OR AUTOMOBILE ACCIDENTS
Please present your auto insurance card, claim number, and adjusters name and number to facilitate care in our office. Please inform us if you have retained an attorney and provide a name and number. There are three options available to you (the PI patient) once we have verified your claims status:

1. Be a self-pay patient for your care and we will submit reports whenever necessary so you can seek reimbursement.
2. Accept YOUR Car Insurance: we will bill (accept assignment) from the med pay (pip) portion of your auto insurance. (no third party insurance accepted)
3. Accept LOP from Attorney: We will accept a letter of protection or doctor’s lien from an attorney and await payment at the time of settlement as long as you remain an active patient.

Although you are ultimately responsible for your bill, we will WAIT FOR SETTLEMENT OF YOUR CLAIM FOR UP TO SIX 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.

*MEDICARE
We do accept assignment from Medicare Part B as a Participating Provider. Medicare has a yearly deductible range of $240. Medicare is very strict on Medical Necessity to bill any service in our office. This includes a care plan that is consistent to provide functional improvement within 90 days. You are required to pay the deductible. Medicare only covers certain services in the office based on the Type of Practitioner the service is done by. Please know that Medicare will ONLY cover manual chiropractic manipulation of the spine (ADJUSTMENT) at 80% of the allowable fee once the and the remaining 20%.

• Medicare Supplement Plans usually pick up the 20% of the ADJUSTMENT, but this is not a guarantee.
• Medicare with Secondary insurance from a spouse or company may or may not pay for these noncovered services. Our office completes and files the forms for Medicare at no charge
• Maintenance- non covered care: Medicare patients are fully responsible for charges of non covered or non-medical necessity services as outlined in your Advance Beneficiary Notice form to be signed and kept on file. The ABN form explains non-covered services are including but not limited to: maintenance adjustments, x-rays, examinations, therapies, orthotics, supports, consultations, and/or nutritional supplements.

IF WE BILL YOUR INSURANCE REMEMBER:

If you receive any correspondence from your insurance carrier pertaining to the care you have received at this office or a request of more information regarding your care, please bring it in as soon as possible, if not it can delay payment or leave you responsible at Self Pay rates if insurance denies care.

1. E.O.B – explanation of benefits from your insurance carrier, if anything looks off, please call our billing department immediately.
2. Formal letters from your insurance carrier regarding authorizations of visits for care in our office.
3. Documents from your insurance carrier that delay coverage due to “preexisting” conditions or question the nature of care in our office.

*INSURANCE PAYMENT
It is very important that we keep your file as up to date as possible. Occasionally, either by mistake, or due to provisions in your policy, the check issued by the insurance company for payment of services rendered in our office, may come to you instead of our office. If you should receive any unexpected check in the mail, please contact us to see if it does represent payment of your bill here. If a credit under $40 remains on your account after 1 year, it will be absolved by the company. All services you are responsible for are due at the time of service. Prepaid care is an estimate of insurance coverage and self-pay coverage, any care not completed will be refunded. Any medical injections that are prepaid and cancelled after the product has been ordered, no refund will be given for that set amount. All costs are explained before the service is rendered and explained on the estimated cost of care form presented by the case manager.

*BY SIGNING BELOW:
I have read and understand the financial policy of Quality of Life Medical Center. I understand that my insurance is an arrangement between myself and my insurance company, not between Quality of Life Medical Center and my insurance company. I request that Quality of Life Medical clinics prepare the customary forms at no charge so that I may obtain insurance benefits. I understand that if the Medical Professionals in charge of my care are maintaining my health (wellness care) and it’s not medically necessary by insurance definition, I am a self-pay policy and insurance will not be billed for those dates of service. I also understand that if my insurance does not respond within 60 days after claims are submitted, or if I suspend or terminate my schedule of care as prescribed by the Medical Team at Quality of Life Medical Center that fees will be due and payable immediately. *For convenience we can store credit card on file securely to allow for speed of checkout and payment plans.

ASSIGNMENT OF HEALTH PLAN BENEFITS AND RIGHTS
AS WELL AS AN APPOINTMENT AND/OR DESIGNATION AS MY PERSONAL REPRESENTATIVE AND AN ERISA/PPACA REPRESENTATIVE AND BENEFICIARY

I understand and agree that (regardless of whatever health insurance or medical benefits I have), I am ultimately responsible to pay Quality of Life Medical Center as well as all employees, employers, representatives, and agents thereof, (hereinafter collectively referred to as “Healthcare Provider”) the balance due on my account for any professional services rendered and for any supplies, tests, or medications provided. I hereby authorize payment of, and assign my rights to, any health insurance or medical plan benefits directly to Healthcare Provider for any and all medical/healthcare services, supplies, tests, treatments, and/or medications that have been or will be rendered or provided; as well as designating and appointing Healthcare Provider as my beneficiary under all health insurance or medical plans which I may have benefits under. I hereby authorize the release of any health status, conditions, symptoms or treatment information contained in your records that is needed to file and process insurance or medical plan claims, to pursue appeals on any denied or partially paid claims, for legal pursuit as to any unpaid or partially paid claims, or to pursue any other remedies necessary in connection with same. I hereby assign directly to Healthcare Provider all rights to payment, benefits, and all other legal rights under, or pursuant to, any health plan (including, but not limited to, any ERISA governed plan/insurance contract, PPACA governed plan/insurance contract) rights that I (or my child, spouse, or dependent) may have under my/our applicable health plan(s) or health insurance policy(ies). I also hereby appoint and designate that Healthcare Provider can act on my/our behalf, as my/our Personal Representative, ERISA Representative, and PPACA Representative as to any claim determination, to request any relevant claim or plan information from the applicable health plan or insurer, to file and pursue appeals and/or legal action (including in my name and on my behalf) to obtain and/or protect benefits and/or payments that are due (or have been previously paid) to either Healthcare Provider, myself, and/or my family members as a result of services rendered by Healthcare Provider, and to pursue any and all remedies to which I/we may be entitled, including the use of legal action against the health plan, the insurer, or any administrator. I hereby also declare that Healthcare Provider is my/our beneficiary regarding my/our health plan as contemplated by both ERISA and PPACA, and that Healthcare Provider can pursue any and all rights that I/we may have under state and/or federal law regarding my/our health plan. This assignment, appointment, and designation will remain in effect unless revoked by me in writing. It is my intent that the effective date of this document shall relate back to include all services, supplies, test, treatments, or medications that have been previously provided by Healthcare Provider. A photocopy or scan or this document is to be considered as valid and as enforceable as the original.

FEMALE

Indicate which of the below you have experienced in the last 1 to 2 months
1=Never; 2=Rarely; 3=Occasionally; 4=Frequently; 5=Constantly

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor’s office of any changes in my medical status. I also authorize the healthcare staff to perform the necessary services I may need.