GLENWOOD CHIROPRACTIC CENTER

The doctor of the future will give no medicine but will interest his patients in the care of the human frame, in diet, and in cause and prevention of disease” –Thomas Edison

We are privileged you have chosen us as your chiropractic care provider. We are committed to providing you and your family with quality patient care. The following is a statement of our Financial Policy, which you need to understand prior to treatment. If you have any questions, please feel free to discuss them with us at any time.

FULL PAYMENT IS DUE AT THE TIME OF SERVICE. We accept cash, checks, and most major credit/debit cards. There will be a $25.00 fee on all returned checks. We also reserve the right to charge $30.00 for missed appointments without 24 hours advance notice.

INSURANCE PATIENTS
Your insurance policy is a contract between you and your insurance company. We have no control over their decisions and the amount they decide to pay. However, as a courtesy to our patients, we will file your primary insurance claims for you.

Before treatment, we will verify your insurance coverage and benefits. Please be aware that your insurance company does not guarantee payment over the phone. We will not know the exact amount they will pay until they respond to the claim. REGARDLESS OF WHAT YOUR INSURANCE COMPANY PAYS, YOU REMAIN FULLY RESPONSIBLE FOR PAYMENT OF YOUR ACCOUNT. Once a payment is received on your claim, we will send you a bill for any remaining balance on your account. Please understand that all co-payments are due the day your treatment is rendered. In order to reduce increased staff time, postage, follow-ups with your insurance companies, and keep your balance to a minimum, we prefer to keep your credit card on file, to be kept in a secure location. We require your authorization to charge your credit card once we receive your Explanation of Benefits from your insurance company. Charges will include your deductible, co-insurance, or non-covered services. You can opt out of this at any time if you choose by notifying us.

I have read and understand above Financial Policy. By signing below, I acknowledge responsibility and agree to the terms above. 

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

In the course of your care as a patient at Glenwood Chiropractic Center, and under Federal Law we may use or disclose personal and health related information about you in the following ways:

• If we are providing health care services to you based on the orders of another health care provider.
• Your health care records, a well as your billing records, may be disclosed to another party, such as but not limited to an insurance carrier, or your employer, if they are responsible for payment of your services.
• If we provide health care services to you in an emergency.
• If there are substantial barriers to communicating with you, but in our professional judgment we believe that you intend for us to provide care.
• If we are ordered by the courts or another appropriate agency.
• Your name, address, phone number and email address may be used by Glenwood Chiropractic Center, P.C for the purpose of contacting you regarding reminding, scheduling, reschedule, thank you cards/emails, birthday cards/emails or information about alternatives to your present care, or other health related information that may be of interest to you.

If you are not available to receive an appointment reminder call, a message may be left on your answering machine, voicemail or with any individual who answers the phone. Further, you have the right to inspect or obtain a copy of the information we will use for these purposes. You also have the right to refuse to provide authorization for this office to contact you regarding these matters. If you do not provide us with authorization, it will not affect the care provided to you or the reimbursement avenues associated with your care.

Any use or disclosure of your protected health information, other than as outlined above, will only be made upon your written authorization.

I can request a copy of the Notice of Privacy Practices of Chiropractor and understand that I have a right to review the Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Chiropractor. The Notice of Privacy Practices for Chiropractor is also posted in the waiting room at Glenwood Chiropractic Center P.C. This Notice of Privacy Practices also describes my rights and duties of the Chiropractor with respect to my protected health information.

“Open-door” adjusting environment

It is the desire of this office to provide chiropractic care in an “open-door” adjusting environment. An “open-door” approach involves the doctor moving from patient care area to patient care area and sometimes leaving the doors open between patient care areas. As a result, patients are occasionally within sight of one another and some ongoing routine details of care are discussed within earshot of other patients and staff. This environment is used for ongoing care and is NOT the environment used for taking patient histories, performing examinations or presenting reports of findings. These procedures are completed in a private, confidential setting.

We are requesting this authorization of you due to various interpretations under Federal law with respect to what is known as “incidental disclosures” of health information. It is our view that the kind of matters related in an “open-door environment are incidental matters, in the event you or someone else would not agree with us, we are providing this disclosure and requesting your authorization.

YOUR SIGNATURE INDICATES YOUR UNDERSTANDING AND AUTHORIZATION OF THESE ACTIVITIES.

If you are a minor, or if you are being represented by another party:

You may revoke this authorization at any time. Revocation may be accomplished by advising us in writing of your desire to withdraw your authorization. Please allow a reasonable processing time for the change in our system to be completed.

PLEASE select the circle next to THE ONE CHOICE which most closely describes your CURRENT condition. 

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. 

THE NATURE OF THE CHIROPRACTIC ADJUSTMENT:
The primary treatment used by Doctors of Chiropractic is spinal manipulative therapy. I will use this procedure to treat you. I may use my hands or a mechanical instrument upon your body in such a way as to move your joints. That may cause an audible "pop" or "click," much as you have experienced when you "crack" your knuckles. You may also feel a sense of movement.

ANALYSIS/EXAMINATION/TREATMENT:
As a part of the analysis, examination, and treatment, you are consenting to the following procedures:

THE MATERIAL RISKS INHERENT IN CHIROPRACTIC ADJUSTMENTS: As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation and 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 manipulation of the neck have been associated with injuries to the arteries of the neck leading to or contributing to serious complications including stroke. Some patients will feel some stiffness and soreness following the first few days of treatment. The Doctor will make every reasonable effort during the examination to screen for contraindications to care, however if you have a condition that would otherwise not come to the Doctor's attention, it is your responsibility to inform the Doctor. Additionally, nutritional remedial and supplements used in our practice are generally considered safe, however, they may involve some risks including, without limit, changes in blood sugar or gastrointestinal upset. They may also interact with certain drugs and may be inappropriate during pregnancy.

THE PROBABILITY OF THOSE RISKS OCCURRING:
Fractures are rare occurrences and generally result from some underlying weakness of the bone which we check for during the taking of your history and during the examination. Stroke and/or arterial dissection caused by chiropractic manipulation of the neck has been the subject of ongoing medical research and debate. The most current research on the topic is inconclusive as to a specific incident of this complication occurring. If there is a causal relationship at all, it is extremely rare and remote. Unfortunately, there is no recognized screening procedure to identify patients with neck pain who are at risk of arterial stroke.

THE AVAILABILITY AND NATURE OF OTHER TREATMENT OPTIONS: Other treatment options for your condition may include:
-Self-administered, over-the-counter analgesics, and rest.
-Medical care and prescription drugs such as anti-inflammatory, muscle relaxants, and pain-killers.
-Hospitalization
-Surgery

If you choose to use one of the above noted "other treatment options" you should be aware that there are risks and benefits of such options and you may wish to discuss these with your primary medical physician.

THE RISKS AND DANGERS ATTENDANT TO REMAINING UNTREATED: Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Over time, this process may complicate your chiropractic treatments making it more difficult and less effective the longer it is postponed.

CONCERNS, QUESTIONS AND ANSWERS:
The doctor-patient relationship is one of mutual trust, confidence, and respect. It is important that we know at all times that you are satisfied with our services, that there is open communication, and that we know of any concerns about your care. If you wait to relate concerns, we may not be able to take meaningful steps to address them. Accordingly, you agree to relay any concerns right away.