Colorado Chiropractic and Rehabilitation Center, LLC

I understand it is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages.

I hereby give my informed consent to receive health care services, evaluation, and treatment rendered according to the applicable standards of care at Colorado Chiropractic and Rehabilitation Center, LLC (hereinafter "CCRC"). I understand that options exist for treatment and all treatments are choices with risks and benefits. If the risks and benefits of a proposed treatment are not clear to me, I understand that I am responsible to request further information from CCRC. The information within my Patient Chart is confidential. I understand that all requests for release of my records, or any portion of my records, must be made in writing to CCRC. Protected health information will only be released with a written authorization, signed by me, and only the minimum disclosure related to my care necessary to fulfill such written request will be provided. I have been provided a copy of CCRC's Privacy Policy Practices and agree to comply with all of CCRC's policies and practices. I understand that I have a responsibility to communicate honestly with my health professionals working at CCRC and to notify them at the earliest time possible of any changes to my condition, health status, re-injury, and/or new injuries and accidents.

I further authorize any health professional working at CCRC to provide tests, procedures, and treatments that are necessary or advisable for the evaluation and management of my health care at CCC and within the scope of CCRC's practice whether rendered by Dr. Walker personally or by another health care provider or staff member under the orders or direction of Dr. Walker.

Financial Responsibility Agreement:

CCRC explained and I understand that CCRC offers a "Time of Service Discount" off the normal fees charged for services rendered if payment in full is made at the time services are rendered. By signing below, I choose not to take advantage of the discounted rates. Instead, I authorize CCRC to bill my insurance company (including workers compensation) the normal fees for service.

I also realize that there is a possibility that my insurance company may not pay some or part of fees for certain services rendered by CCRC. CCRC does not promise or guarantee that services rendered to me will be paid by my insurance company. I agree to pay for all charges for services rendered to me if my insurance company reduces or denies payment for any services provided to me by CCRC. Workers Compensation patients with an open claim are not responsible for charges and services rendered if they have an open and accepted Workers Compensation Claim. CCRC will not balance bill services provided to an accepted claim for a Workers Compensation patient who has been provided services by CCRC. Any services provided after a denial of my claim or closure of my claim (without authorized maintenance services) will be my responsibility to pay in full. I am required to notify CCRC if my claim is denied for any reason and contact them to cancel all services immediately. I am responsible to pay any services provided to me after denial of my Workers Compensation Claim.

I UNDERSTAND THAT I AM PERSONALLY FINANCIALLY RESPONSIBLE and obligated to pay, in full, THE ENTIRE BILLED AMOUNT, for any and all health care and/or professional services rendered to me WHETHER OR NOT MY INSURANCE PAYS any portion of the charges incurred by me. I understand that I am personally responsible for any charges, and unpaid portions of charges, not covered by insurance. I understand that amounts unpaid for over 90 days from the date services were rendered are past-due and subject to a monthly finance charge of 1.5% and an annual finance charge of 18%.

I understand and agree that if I fail to make any payments in a timely manner (including but not limited to the balances after insurance benefits and/or settlement proceeds have been received), after such default and upon referral to a collection agency, attorney, or small claims court by CCRC, I will be responsible for all costs of collection, including, but not limited to, collection agency fees up to 50% collection fees, court costs, and CCRC's attorney fees.

• Fees
  I understand that Colorado Chiropractic and Rehabilitation Center, LLC is an independent clinic and sets its own fees for all services to conform to reasonable and customary fees for the services provided through this facility (this includes services provided by Dr. Walker, or any other member of the clinic staff or coverage staff). I understand that fees are subject to change without notice. I understand that a complete list of services and fees are available for my review upon written request.

• Cancelation, Missed Appointment and Rescheduling Policy.
  I agree that I may be charged a fee for any no-show, late cancelation, or rescheduling made less than 24-hours before my scheduled appointment. If you are a Workers Compensation patient, please note that missed appointments, no show or late cancellations (less than 24 hours' notice) are not billed to you but may seriously affect your claim and your ability to continue to treat under your claim with our office.

• Late Fees and Monthly Finance Charges.
  I agree that I may be charged late fees and/or a monthly finance charge if there is any outstanding balance owning on my account for over 30 days.

• Time of Service Discount Option.
  I agree that, at the sole option and discretion of Colorado Chiropractic and Rehabilitation Center, LLC, I may be offered a Time of Service Discount on services rendered and that this is a reduction from the customary fees for services at Colorado Chiropractic and Rehabilitation Center, LLC. This requires that I pay in full at the time of service (the same day of my service or before my service). If I do not pay in full at or before the time of service, I will be charged the full customary fee for services with no reduction, and I agree that I am personally and solely responsible for the full-billed amount of the services rendered.

• Other Accidents, Injuries, and Claims.
  I understand that if I am involved in a Workers Compensation, Auto Accident, Personal Injury Claim, or Third-Party Claim of any kind after beginning treatment with Colorado Chiropractic and Rehabilitation Center, LLC, any existing financial agreement(s) or Time of Service Discount are suspended and terminate. I understand that I am required to notify Colorado Chiropractic and Rehabilitation Center, LLC. I further understand and agree that Colorado Chiropractic and Rehabilitation Center, LLC, may unilaterally terminate any financial agreement(s) or Time of Service Discount at any time for any reason with written notice.

My signature below confirms I read, understand, and expressly to adhere with and agree to be bound by Colorado Chiropractic and Rehabilitation Center, LLC's Office Policy and all terms and conditions herein.

Please list your relative's health issues, current age or age at time of death with cause of death. 

Hospitalizations, Operations, Serious Illnesses, Auto Accidents or Prior Work Injuries:

Please read carefully:

Instructions: Please select the number that best describes the question being asked.

Note: If you have more than one complaint, please answer each question for each individual complaint and indicate the score for each complaint. Please indicate your pain level right now, average pain, and pain at its best and worst.

Example:

Please read:

This survey asks for your views about how your pain now affects how you function in everyday activities. This information will help you and your doctor know how you feel and how well you are able to do your daily tasks at this time.

Please answer every question by selecting an option along the line to show how much your pain problem has affected you (from having no problems at all to having the most severe problems you can imagine).

BE SURE TO ANSWER ALL QUESTIONS

Reproduced with Permission from: Anagnostis C, Gatchel RJ Mayer TG, The Pain Disability Questionaire. Spine 2004, 29:2290-2302.

PLEASE USE THE LETTERS TO INDICATE TYPE AND LOCATION OF PAIN

A= Ache,  B= Burning,  C= Cramping,  S= Stabbing,  T= Tightness/Tension,  N= Numbness/Tingling

I have read and understand the Office Policy for Colorado Chiropractic and Rehabilitation Center, which states I must give at least 24-hours’ notice for cancellation of ANY appointment, or I may be charged a FEE.  This could also result in termination of my treatment for non-compliancy and this may affect my workers compensation claim.