INITIAL HEALTH STATUS

I certify to the best of my knowledge, the above information is complete and accurate. If the health plan information is not accurate, or if I am not eligible to receive a health care benefit through this practitioner, I understand that I am liable for all charges for services rendered and I agree to notify this practitioner immediately whenever I have changes in my health condition or health plan coverage in the future. I understand that my chiropractor may need to contact my physician if my condition needs to be co-managed. Therefore I give authorization to my chiropractor to contact my physician, if necessary.

The privacy of your personal and health information is important to us. Please review the following information carefully. This notice describes how medical information about you may be used and disclosed.

Body In Motion Chiropractic understands the importance of keeping your personal and health information  private. Personal and health information includes both medical information and  individually identifiable information, such as your name, address, telephone number or social security number. This is a notice of our confidentiality and privacy practices, our legal duties and your rights concerning your personal and health information. We protect your personal and health information in electronic, written and oral forms when used in our office. In accordance with State and Federal law, we are providing you with a statement regarding our privacy practices.

Body In Motion Chiropractic may use and disclose your personal and health information, without your authorization, only in the following ways:
Treatment: We may disclose your personal and health information to your health insurance provider if they request this information.
Required by Law: We will use or disclose your personal and health information when we are required to do so by law, in response to a court order, subpoena, discovery request or other lawful process.

With your Written Authorization:
We may not use or disclose your personal and health information without your written authorization (example: from an attorney’s office, or other insurance office as in the case of a personal injury motor vehicle accident involving a third party insurance company). There is a $15.00 copy fee assessed with this disclosure.

Individual Rights: You have the right to access your personal and health information. You must make a request in writing to obtain access to your personal and health information or to obtain photo copies of your personal and health information. Please note that there may be a copy fee assessed.
You have the right to amend your personal and health information. You must make a request in writing to obtain an amendment. Your written request must explain why the information should be amended. If we agree to amend the information for you, we will make reasonable efforts to inform your insurance company or attorney of such changes.
If you want more information about our privacy practices or have questions or concerns, please feel free to contact Dr. Julian Ovtcharov. If you are concerned that we may have violated your privacy rights or you disagree with a decision we made about access to your personal and health information, you may submit a written complaint to us and to the U.S. Department of Health and Human Services.

I have read and understand the above information in regards to the confidentiality and privacy practices of Body In Motion Chiropractic.

I, the undersigned, have voluntarily requested that Dr. Julian Ovtcharov assist me in the management of my health concerns. I have read and agree to the Office Policies and Procedures. I understand that Dr. Ovtcharov is a chiropractor and that his services are not to be construed or serve as a substitute for standard medical care. Dr. Ovtcharov recommends that I undergo regular routine medical check-ups by my medical doctor.

I hereby request and consent to the performance of conservative, non-invasive treatment to the joints and soft tissue structures. I understand that the procedures may consist of adjustments/manipulations involving the movement of joints and soft tissue. Routine examination may include inspection, palpation, auscultation, percussion, and orthopedic and neurological testing.

Although spinal manipulation is considered to be one of the safest, most effective forms of therapy for musculoskeletal problems, I am aware that there are possible risks and complications associated with these procedures. Some risks include, but are not limited to: soreness, bruising, dizziness, fractures, strokes, dislocations, sprains, and physical therapy burns. A thorough health history and tests will be performed to minimize the risk of any complications from treatment and I freely assume these risks.

I understand that at any point during the course of my treatment, I have the right to refuse the recommended treatment given by the doctor, or request an alternative treatment type or modality, within the scope of the doctor’s practice and expertise. However, I understand that I may not achieve the best results for my condition if I so choose.

I have had an opportunity to discuss, to my satisfaction, with the treating doctor of chiropractic and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and other procedures.

I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named 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 from Dr. Ovtcharov at Body In Motion Chiropractic.

To be completed by patient:

To be completed by patient’s legal guardian or representative (i.e. if patient is a minor, or legally incapacitated):

Paid At Time of Service Discount Fee for Non-Insurance Patients Only

A regular treatment with Dr. Julian Ovtcharov consists of soft tissue therapy using Active Release Technique/Myofascial Release Technique, P.N.F. and or Graston followed by chiropractic adjustments to select areas of joint fixation. Kinesiology Tape may be administered at the end of treatment if Dr.Ovtcharov determines it will be beneficial in the healing and recovery of the patient’s condition.

A Time of Service Payment will be collected for all services provided that day.

I understand that A.R.T./M.R.T., P.N.F. , Graston and extremity adjusting may not a covered service by Health Insurance Companies, and agree to pay the $35.00 for the treatment in addition to my co-pay or other services not covered by my insurance.

Pay at Time of Service Plan
I will pay for all treatments and services in full at the time they are received

Agreement To Pay For Services Rendered
By my signature, I signify that I understand that I am personally responsible for the payment of all care rendered to me while at Body In Motion Chiropractic. If I receive a bill from Body In Motion Chiropractic, I agree to pay it in full within 30 days from the time I received care.

Guardian or Personal Representative

If appointments are missed or rescheduled within 24 hours of the time, the patient will be charged the full amount of the visit. If appointments are scheduled outside normal office hours, there will be a $60 charge on addition to the normal fee’s.