I hereby give my permission for Medical Partners of FL, LLC to provide me medical treatment.

To the patient: Please read this entire document prior to signing it. It is important that you understand the information contained in this document. Please ask questions before you sign if there is anything that is unclear.

EXAMINATION/TREATMENT

Potential treatment options can include: Range of motion testing, Palpation, Vital signs, Muscle strength testing, Orthopedic testing, Neurological exam, Ultrasound / EMS, Hot / Cold therapy, Myofascial release, Radiographic Studies / MRI, Spinal mobilization / manipulation, Acupuncture.

MATERIAL RISKS INHERENT TO THERAPY

As with any healthcare procedure, there are certain complications that may arise during physical and chiropractic therapy. These complications include, but are not limited to: fractures, disc injuries, dislocations, muscle strain, cervical myelopathy, costovertebral strains and separations and burns. Some types of manipulations of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. Some patients will feel some stiffness and soreness after the first few treatments. We will make every reasonable effort during your exam to screen for contraindications to care, however if you have a condition that would otherwise not come to my attention, it is your responsibility to inform us.

PROBABILITY OF RISK

Fractures are rare occurrences and generally result from some underlying weakness of the bone which we check for during the history and examination. Stroke has been the subject of tremendous disagreement. The incidences of stroke are exceedingly rare and are estimated to occur between one in one million and one in five million cervical manipulations. The other complications are also generally described as rare.

AVAILABILITY OF OTHER TREATMENT OPTIONS

Other treatment options may include: Over the counter analgesics and anti-inflammatories, Prescription medications, Injections, Surgery. These will be discussed with you at the time of examination.

RISK AND DANGER OF REMAINING UNTREATED

Remaining untreated will allow the formations of adhesions and reduce mobility which may cascade a pain/spasm reaction further reducing mobility. Over time, this process may complicate treatment making it more difficult and less effective the longer it is postponed.

PLEASE SIGN THAT YOU UNDERSTAND AND READ THE ABOVE

I have read the above explanation of therapy treatments. I have discussed it with the doctor(s) at Dr.Tanya Schrumpf, DC, Inc and Medical Partners of FL, LLC and have had my questions answered to my satisfaction. By signing below, I state that I have weighed the risks involved in undergoing treatment and have decided that it is in my best interest to undergo the treatment recommended. Having been informed of the risks, I hereby give my consent to that treatment.

Financial Agreement

I  have requested medical services and consent to treatment from Medical Partners of FL, LLC, and any service provider or physician within Medical Partners of FL, LLC employment, on behalf of myself and/or my dependents. I understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized.

I hereby assign all major medical benefits, including personal injury protection (No Fault) benefits if applicable, to which I am entitled. I hereby authorize and direct my insurance carrier(s) to issue payment check(s) directly to Medical Partners of FL, LLC for any medical services rendered to myself and/or my dependents. This assignment is strictly for purposes of direct billing and payment to Medical Partners of FL, LLC. I understand I am responsible for any amount not covered by insurance.

Notice of Privacy Practices: By signing this document, I also acknowledge that I have been offered a copy of the organization’s Notice of Privacy Practices. This acknowledgement is required by the Health Insurance Portability and Accountability Act (HIPAA) to ensure that I have been made aware of my privacy rights.

Not all insurance plans cover all services. In the event your insurance plan determines a service to be “not covered”, you will be responsible for the complete charge. Payment is due 30 days upon receipt of a statement from our office.

Secondary Insurance: As a courtesy, we do file with secondary insurance carriers. However, in the event the secondary insurance carrier does not pay within ninety (90) days, patients will be billed.

If it becomes necessary to collect any amount due through an attorney or collection agency, then the patient agrees to pay all reasonable costs of collection, including attorney’s fees, whether a suit is filed or not.

Your insurance company may require a Copayment/ Coinsurance to be paid to Medical Partners of FL, LLC when you seek medical services. In turn, we are contractually obligated to collect any deductible, co-payment, or coinsurance from our patients. Medical Partners of FL, LLC collects toward deductibles in advance. All patients with a deductible will be expected to pay per appointment toward that deductible.

Our office will verify your health insurance benefits. The insurance verification is only a summary of benefits and does not guarantee coverage and payment. It is each patient's responsibility to provide Medical Partners of FL, LLC with updated insurance information when applicable.

Payment is due at the time services are rendered: We accept cash, personal checks, major credit cards (i.e., Visa, MasterCard, Discover, American Express.) Returned checks are subject to a thirty-five dollar ($35) NSF fee or 5% of the face value of the check and you will lose the privilege to write checks in this office in the future.

By signing below you acknowledge that you are responsible for the payment of any co-payment, coinsurance, or deductible for health services provided to you, or your dependent.

I, the patient, promise and attest that I will pay the required deductible, co-payment, or coinsurance to Dr.Tanya Schrumpf, DC, Inc and Medical Partners of FL, LLC within thirty (30) business days from receiving a bill. Patient statements are mailed when explanation of benefits are received from your insurance company.

HIPAA Privacy Rule of Patient Authorization Agreement

Authorization for the Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.508(a))

I understand that as part of my healthcare, this Practice originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves as:

a basis for planning my care and treatment;
a means of communication among the health professionals who may contribute to my health care;
a source of information for applying my diagnosis and surgical information to my bill;
a means by which a third-party payer can verify that services billed were actually provided;
a tool for routine health care operations such as assessing quality and reviewing the competence of healthcare professionals.

I have been provided with a copy of the Notice of Privacy Practices that provides a more complete description of information uses and disclosures. I understand that as part of my care and treatment it may be necessary to provide my Protected Health Information to another covered entity. I have the right to review this Practice’s notice prior to signing this authorization. I authorize the disclosure of my Protected Health Information as specified below for the purposes and to the parties designated by me.

Privacy Rule of Patient Consent Agreement

Consent to the Use and Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.506(a))

I understand that:

I have the right to review this Practice’s Notice of Information practices prior to signing this consent; that this Practice reserves the right to change the notice and practices and that prior to implementation will mail a copy of any notice to the address I’ve provided, if requested;
I have the right to object to the use of my health information for directory purposes;
I have the right to request restrictions as to how my Protected Health Information may be used or disclosed to carry out treatment, payment, or healthcare operations, and that this Practice is not required by law to agree to the restrictions requested;
I may revoke this consent in writing at any time, except to the extent that this Practice has already taken action in reliance thereon.

I consent to the above agreements by signing on this line