Patient Information

I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic.

I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.

Informed Consent for Chiropractic Care

When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both of us to be working for the same objective.  It is important that each patient understand both the objective(s) and the method(s) that will be used to attain this objective.  This will prevent any confusion or disappointment.  You have the right, as a patient, to be informed about the condition and the recommended care to be provided so that you make the decision whether or not to undergo chiropractic care after being advised of the known benefits, risks, and alternatives. 

If at the beginning or during the course of care we encounter a non-chiropractic or unusual findings, we will advise you of those findings and recommend some further testing or refer you out to another health care provider.

Chiropractic care has been proven to be very safe and effective.  It is not unusual however, to be sore after your first few corrective adjustments.  Although rare it is possible to suffer from other side effects; i.e. muscle spasms, stiffness, rib fracture, headache, dizziness and stroke. 

All questions regarding the doctor's objective to my care in this office has been answered to my complete satisfaction.  The benefits, risks and alternatives of chiropractic care have been explained to me to my satisfaction.  I have read and fully understand the above statements and therefore accept chiropractic care on this basis.

Mark the diagram as follows:    

A – Ache, B - Burning, N - Numbness, P - Pins & Needles, S-Stabbing, O - Other – (Describe)

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW CAREFULLY.

Our Obligations

We are required by law to:

• Maintain the privacy of protected health information
• Give you the notice of your legal duties and privacy practices regarding health information about you
• Follow the terms of our notice that is currently in effect

How We May Use and Disclose Health Information

Described as follows are the ways we may use and disclose health information that identifies you (“Health Information”). Except for the following purposes, We will use and disclose health information only with your written permission. You may revoke such permissions at any time by writing to our practice’s privacy officer.

Treatment. We may use and disclose Health Information for your treatment and to provide you with treatment-related health care services. For example, we may disclose Health Information to doctors, nurses, technicians, or other personnel, including people outside our office, who are involved in your medical care and need the information to provide you with medical care.           

Payment. We may use and disclose Health Information so that we or others may bill and receive payment from you, an insurance company, or a third party for treatment and services you receive. For example, we may give your health plan information so that they will pay for your treatment.

Health Care Operations. We may use and disclose Health Information for health care operation purposes. These uses and disclosures are necessary to make sure that all of our patients receive quality care to operate and manage our office. For example, we may use and disclose information to make sure the obstetric or gynecologic care you receive is of the highest quality. We also may share information with our entities that have a relationship with you (for example, your health plan) for their health care operation activities.

Appointment Reminders, Treatment Alternatives, and Health Related Benefits and Services. We may use and disclose Health Information to contact you and remind you that you have an appointment with us. We also may use and disclose Health Information to tell you about treatment alternatives or health related benefits and services that may be of interest to you.       

Individuals Involved in Your Care or Payment for Your Care. When appropriate, we may share Health Information with a person who is involved in your medical care or payment for your care, such as your family or a close friend. We also may notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort.

Research. Under certain circumstances, we may use and disclose Health Information for research. For example, a research project may involve comparing the health of patients who receive one treatment to those who receive another for the same condition. Before we use or disclose Health Information for research, the project will go through a special approval process. Even without special approval, we may permit researchers to look at records to help them identify patients who may be included in their research project or for other similar purposes.

 

Special Situations

As required by law. We will disclose Health Information when required to do so by international, federal, state, or local law.

To Avert a Serious Threat to Health of Safety. We will disclose Health Information when necessary to prevent a serious threat to your health and safety or the public, or another person. Disclosure, however, will be made only to someone who may be able to help provide treatment.                     

Business Associates. We may disclose Health Information to our business associates that perform functions on our behalf or to provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than that as specific in our contract. 

Organ and Tissue Donation. If you are an organ donor, we may use or release Health Information to organizations that handle organ procurement or other entities engaged in procurement; banking or transportation of organs, eyes, or tissues to facilitate organ, eye, or tissue donation, and transplantation.            

Military and Veterans. If you are a member of the army forces, we may use or release Health Information as required by military command authorities. We also may release Health Information to the appropriate foreign military authority if you are a member of a foreign military.                   

Worker’s Compensation. We may release Health Information for worker’s compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks. We may disclose Health Information for public health activities. These activities generally include disclosure to prevent or control disease, injury, or disability; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; inform a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and report to the appropriate government authority if we believe a patient has been a victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required by law.                         

Health Oversight Activities. We may disclose Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes. If you are involved in a lawsuit of a dispute, we may disclose Health Information in response to a court or a court administrator order. We also may disclose Health Information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement. We may release Health Information if asked by a law enforcement official if the information is: 1) in response to a court order, subpoena, warrant, summons, or similar process; 2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; 3) about the victim of crime even if, under certain circumstances, we are unable to obtain the person’s agreement; 4) about a death we believe may be the result of criminal conduct; 5) about criminal conduct on our premises and; 6)in an emergency to report a crime to the location of the crime if victims, or the identity, description, or location of the person who committed the crime.                

Coroners, Medical Examiners, Funeral Directors. We may release Health Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release Health Information to funeral directors as necessary for their duties.

National Security and Intelligence Activities. We may release Health Information to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state, or to conduct special investigations.

Protective Services and Intelligence Activities. We may release Health Information to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state, or to conduct special investigations.

Inmates or Individuals in Custody. If you are an inmate of a correctional institution or other custody of a law enforcement official, we may release Health Information to the correctional institution or law enforcement official. This release would be made if necessary 1) for the institution to provide you with health care; 2) to protect your health and safety or the health and safety of others, or; 3) for the safety and security of the correctional institution.

Your Rights

You have the following rights regarding Health Information we have about you:

Right to Inspect and Copy. You have the right to inspect and copy Health Information that we may used to make decisions about your care or payment for your care. This includes medical and billing records, other than psychotherapy notes. To inspect and copy this information, you must make your request in writing, to our Privacy Officer.

Right to Amend. If you feel that Health Information we have is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for our office. To request an amendment, you must make your request, in writing, to our Privacy Officer.

Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures we made of Health Information for purposes other than treatment, payment, and health care operations or for which you provided written authorization. To request an accounting of disclosures, you must make your request, in writing, to our Privacy Officer.

Right to Request Restrictions. You have the right to request a restriction or limitation on the Health Information we use or disclose for treatment, payment, or health care operation. You also have a right to request a limit on the Health Information we disclose to someone involved in your care or the payment for your care, like a family member or friend. For example, you can ask that we not share information about your particular diagnosis or treatment with your spouse. To request a restriction, you must make your request, in writing, to our Privacy Officer. We are not required to agree with your request. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment.

Right to Request Confidential Communication. You have the right to request that we communicate with you about your medical matters in a certain way or at a certain location. For example, you can ask that we contact you only by mail or at work. To request confidential communications, you must make your request, in writing, to our Privacy Officer. Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You must ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice by contacting our office.

Changes to This Notice. We reserve the right to change this notice and make the new notice apply to Health Information we already have as well as any information we receive in the future. We will post a current copy of our notice at our office. The notice will contain the effective date on the first page, in the top right hand corner.

Complaints. If you believe your privacy has been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services.  To file a complaint with our office, contact our Privacy Officer. All complaints must be made in writing. You will not be penalized for filing a complaint.

By Subscribing my name below, I acknowledge receipt of a copy of this notice, and my understanding and my agreement to its terms.*                  

Thank you for trusting your chiropractic care to Injury Care Chiropractic. When you schedule an appointment with Us  we set aside enough time to provide you with the highest quality care. Should you need to cancel or rescheduled an appointment please contact our office as soon as possible, and no later than 24 hours prior to your scheduled appointment. This gives us time to schedule other patients who may be waiting for an appointment. Please see our Appointment Cancellation/No Show Policy below:

• Patient who fails to show or cancels/reschedules an appointment and has not contacted our office with at least 24 hours notice will be considered a No Show and charged a $35.00 fee. 
• Any established patient who fails to show or cancels/reschedules an appointment with no 24 hours notice a second time will be charged a $50.00 fee.
• The fee is charged to the patient, not the insurance company, and is due at the time of the patient’s next office visit.
• As a courtesy, when time allows, we make reminder calls for appointments. If you do not receive a reminder call or message, the above Policy will remain in effect.

We understand there may be times when an unforeseen emergency occurs, and you may not be able to keep your scheduled appointment. If you should experience extenuating circumstances please contact our Office Manager, who may be able to waive the No Show fee. You may contact Injury Care Chiropractic, 24 hours a day, 7 days a week at the numbers below. Should it be after regular business hours Monday through Thursday, or a weekend, you may leave a message. Messages left at our location are acceptable.

Injury Care Chiropractic    Phone: 702.255.7800   TEXT: 702-469-0993

I have read and understand the Medical Appointment Cancellation/No Show Policy and agree to its terms.

TO:

RE:

I understand the information to be released or disclosed may include information relating to sexually transmitted diseases, acquired immunodeficiency virus (HIV), and alcohol and drug abuse. I authorize the release or disclosure of this type of information.

This protected health information is disclosed for the following purposes: Medical treatment or personal injury claim(s).

You are authorized to release the above records to the following:

Injury Care Chiropractic

6130 West Sahara Avenue

Las Vegas, NV 89146

Fax:(702) 778-1495

 

I understand the following:

1. I have a right to revoke this authorization in writing at any time, except to the extent information has been released in reliance upon this authorization.
2. The information released in response to this authorization may be re-disclosed to other parties.
3. My treatment or payment for my treatment cannot be conditioned on the signing of this authorization.

Any facsimile, copy or photocopy of the authorization shall authorize you to release the records requested herein. This authorization shall be in force and effect until two years from date of execution at which time this authorization expires.

The following is our Financial Policy. If you have any questions or concern about our payment policies, please do not hesitate to ask for our Billing Department.

Definition of Terms:

• Service Date: the date the service is provided
• Account Balance: the total amount due, including all fees, costs and interest as set forth herein.

Guarantee of Payment: I hereby acknowledge I am responsible for the payment of all charges for products and/or services rendered to me or for the benefit of the person indicated upon which I am the responsible party. By signing this document I personally guarantee the payment of these charges for services and/or products provided. I agree this authorization shall be valid until rescinded in writing or replaced by one of a later date.

Collection of Delinquent Account Terms: Failure to pay my account balance in full within 30 days from any Service Date is considered a delinquent account and may result in charges being added to my Account Balance, including but not limited to as follows:

1. Delinquent accounts will accrue interest at the contract rate of 24% per annum (2% per month), until paid in full.
2. Any delinquent account may be forwarded and assigned to any collection agency without notice to you with any and all collection agency fee assessed by the collection agency being added to your Account Balance, with or without suit.
3. A delinquent account assigned to a collection agency will be charged a collection agency fee of 40% to 50% of the Account Balance, with said fee being added to your Account Balance, with or without suit.
4. If legal action is required to collect this account, in addition to any Account Balances, I/We individually or as the person’s representative who signs below, agrees to pay any and all collection agency fee assessed as part of my Account balance with interest accruing thereon as set forth herein, plus any and all costs associated with such collection activity, including but not limited to all collection fees, attorney fees, court fees, service fees, skip tracing fees and costs in addition to any miscellaneous fees the court of jurisdiction may award.

Returned Checks: There is a fee (currently $25.00) for any check returned by the bank plus bank servicing fees. This amount may change at any time.

Assignment: If this account becomes delinquent, I/We hereby authorize this office to assign this account and/or to release any necessary information to any third party collection agency.  Additionally, if my account is assigned to any collection agency, I/We hereby authorize the collection agency the right to report this account as delinquent to all the Credit Bureaus.

Signature of Understanding: I have read and understand the financial policy.  By signing this form, I consent to the above terms and conditions and understand that it is my responsibility for assuring that I timely fulfill my financial obligations in full without delay. I hereby accept financial responsibility for all charges incurred whether or not I receive any invoice and/or payment reminder.