PEDIATRIC HISTORY FORM

Check any of the Following conditions your child has suffered from during the past six months:

Birth Weight:

According to the National Safety Council, approximately 50% of children fall head first from a high place during their first year of life

(i.e. bed, changing table, down stairs, etc

We are a provider for these insurances

Blue Cross Blue Shield PPO (we are not in network for POS or HMO)

United Healthcare

Iowa Medicaid

Wellpoint

Iowa Total Care

Molina

The first visit at Gabel Chiropractic will be $175-$200. This includes an exam, x-rays if needed, and an adjustment on your first in person visit. 

We will require a credit/debit card on file for all patients. 

 

We do not have insurance the Gabel Chiropractic is a provider for. I will pay for my chiropractic visits.

The first visit will be $175 and $45 each visit after that.

Our office requires a credit card on file. I understand the financial policy.

If you wish for us to submit to your health insurance we will need a copy of your insurance card. We will verify your benefits and once they are verified we will then submit your claims on a timely basis. You are responsible for paying co-payment, co-insurance and deductible amounts at the time services are rendered. There will be a service charge added to your bill for overdue payments. All services rendered are charged directly to the patient and the patient is ultimately responsible for the account regardless of insurance coverage. Our office will bill your insurance company a maximum of 2 times per date of service: #1- - The day of your appointment. #2- 60 days after your appointment if your claim has not been paid. At 90 days: All accounts are payable by the patient/guarantor if insurance has not been received. Further insurance appeal becomes the patient/guarantor's responsibility.

This clinic DOES NOT promise that an insurance company will pay. Nor does the clinic promise that an insurancecompany should pay the fees as charged. The clinic will not enter into a dispute with an insurance company for reimbursement or the amount of reimbursement. This is the patient's obligation. Gabel Chiropractic will submit claims two times for consideration. If the account is still not paid, it is the responsibility of the patient/guarantor.

Policy Holder Name Policy Holder DOB Policy number Policy group number

We require a credit card on file.

INFORMED CONSENT UNDER IOWA CODE SECTION 147.137

The profession of chiropractic, dentistry, medicine and surgery, nursing, optometry, osteopathy, osteopathic medicine and surgery, pharmacy, physical therapy, podiatry, psychology, and others are regulated in the state of Iowa under Iowa Code Chapter 147. Patient care provided by those above listed professions, including chiropractic, have known risks which may include death, brain damage, quadriplegia, paraplegia, the loss of function of any organ or limb, or disfiguring scars associated with such care and treatment. For your information, the following is routinely furnished to all who consider chiropractic care at this clinic. Gabel Chiropractic is staffed with a licensed doctor of chiropractic. Chiropractic is a science, which concerns itself with the relationship between structure (primarily the spine) and function (primarily the spine) of the body as the relationship may affect the restoration and preservation of health.

NATURE AND PURPOSE OF CHIROPRACTIC PROCEDURES

The practice of chiropractic includes many standard examination and testing procedures. These include physical examination, orthopedic and neurological testing, palpation, specialized instrumentations, laboratory tests, radiology examinations, physical therapy and related rehabilitative procedures. Additionally, there is a procedure unique to the chiropractic profession -- the chiropractic spinal adjustment. Adjustments are made by chiropractors to correct spinal and extremity joint subluxations. One of the most common disturbances to the nervous system is the vertebral subluxation. This condition exists where one or more vertebrae in the spine are misaligned sufficiently to cause interference and/or irritation of the nervous system. The primary goal in chiropractic health care is the removal of nerve interference caused by such subluxation(s There are a number of different adjusting techniques, some utilizing specially designed equipment. Adjustments are usually performed by hand but may be performed by hand-guided instruments. A chiropractic adjustment is the application of a quick precise movement over a very short distance to a specific segmental contact point of a vertebra. Not only should you understand the benefits of chiropractic care in restoring and maintaining good health, but also you should be aware of the existence of some inherent risks and limitations. These are seldom enough to contraindicate care, but should be considered in varying degrees, and have some risks associated with them. Risks associated with some chiropractic adjusting procedures may include musculoskeletal sprain/strain, neurological deficits, osseous fracture, vertebral artery syndrome (VAS), including stroke and perhaps, death through complicating factors.

AUTHORIZATION FOR CHIROPRACTIC CARE OF A MINOR OR PERSON UNABLE TO CONSENT

I have been informed of the nature and purpose of chiropractic care, the possible consequences of the care, and the risks of the care, including the risk that care may not accomplish the desired objective. Reasonable alternative treatments have been explained, including risks, consequences, and probable effectiveness of each and I have been advised of the possible consequences if no care is provided. I acknowledge that no guarantees have been made to me concerning the results of the care and treatment.

I HAVE READ THE PRECEDING PARAGRAPHS. I UNDERSTAND THE INFORMATION PROVIDED. THE INFORMATION PROVIDED HAS BEEN EXPLAINED TO ME AND ALL QUESTIONS, WHICH I HAVE ASKED, HAVE BEEN ANSWERED TO MY SATISFACTION.

HAVING THIS KNOWLEDGE, I KNOWINGLY AUTHORIZE DR. ANGELA GABEL TO PROCEED WITH CHIROPRACTIC CARE AND TREATMENT.

In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual's office instead of the individual's home. We will contact patients via text message, email message, and phone messages.

If you would like a spouse or parent to be able to ask about appointments and care please fill in the name(s) below.

to schedule & cancel my appointments.

to ask about my current treatment plans and care.

The Privacy Rule generally requires healthcare providers to take reasonable steps to limit the use or disclosure of, and requests for PHI to the minimum necessary to accomplish the intended purpose. These provisions do not apply to uses or disclosures made pursuant to an authorization requested by an individual.

Patients will be notified of the "Attendance Policy" at the time of initial registration and when there are any changes to the policy. We require a 20-hour notice if you are unable to keep your appointment. Patients who fail to present for a scheduled appointment without contacting the practice 20 hours prior to cancel the appointment will be considered a "no show". Three "no shows" in a 6 month period may result in a 6 month appointment hold and a $30 appointment fee. Patients with multiple rescheduled appointments will also fall under our Attendance Policy. When you cancel or reschedule on short notice, other patients that are in need of treatment cannot be seen and that time is wasted. Therefore, we require a 20-hour notice if you are unable to keep your appointment. Implementation: If a patient fails to be compliant with our policy the following steps may be taken: 1st Occurrence -Patient will be charged a fifteen dollar ($15.00) appointment fee and text to be notified of a missed appointment. Your credit card on file will be debited the charge. 2nd Occurrence - -Patient will be charged a fifteen dollar ($15.00) appointment fee and text to be notified of a missed appointment. Your credit card on file will be debited the charge. Any future missed appointments can result in a hold or termination from the practice. 3rd Occurrence - Patient will be charged a thirty dollar ($30) appointment fee. The patient can also be placed on a 6 month hold. This means a patient may not book any appointments for 6 months after the date of their last missed appointment. At our practice, we understand that certain circumstances may cause you to cancel your appointments. Our practice firmly believes that a good relationship is based upon understanding and good communication. Please feel free to contact our office about any questions you may have about our Appointment Attendance Policy.