Trinity Integrated Health & Wellness Center

ASSIGNMENT OF HEALTH PLAN BENEFITS AND RIGHTS
AS WELL AS AN APPOINMENT AND/OR DESIGNATION AS MY PERSONAL REPRESENTATIVE AND
AN ERISA/PPACA REPRESENTATIVE AND BENEFICIARY

I understand and agree that (regardless of whatever health insurance or medical benefits I have). I am ultimately responsible to pay Trinity Integrated Health & Wellness Center as well as all employees, employers, representatives, and agents thereof, (hereinafter collectively referred to as “Health Provider”) the balance due on my account for any professional services rendered and for any supplies, tests, or medications provided. I hereby authorize payment of, and assign my rights to, any health insurance or medical plan benefits directly to Healthcare Provider for any and all medical/healthcare services, supplies, tests, treatments, and/or medications that have been or will be rendered or provided; as well as designating and appointing Healthcare Provider as my beneficiary under all health insurance or medical plans which I may have benefits under. I hereby authorize the release of any health status, conditions, symptoms, or treatment information contained in your records that is needed to file and process insurance or medical plan claims, to pursue appeals on any denied or partially paid claims, for legal pursuit as to any unpaid or partially paid claims, or to pursue any other remedies necessary in connection with same. I hereby assign directly to Healthcare Provider all rights to payment, benefits, and all other legal rights under, or pursuant to, any health plan (including, but not limited to, any ERISA governed plan/insurance contact, PPACA governed plan/ insurance contact) rights that I ( or my child, spouse or dependent) may have under my/our applicable health plan(s) or heath insurance policy(ies). I also hereby appoint and designate the Healthcare Provider can act on my/our behalf, as my/our Personal Representative, ERISA Representative, and PPACA Representative as to any claim determination, to request any relevant claim or plan information from the applicable health plan or insurer, to file and pursue appeals and/or legal action (including in my name and on my behalf) to obtain and/or protect benefits and/or payments that are due (or have been previously paid) to either Healthcare Provider, myself, and/or my family members as a results of services rendered by Healthcare Provider, and to pursue any and all remedies to which I/we may be entitled, including the use of legal action against the health plan, the insurer, or any administrator. I hereby also declare that Healthcare Provider is my/our beneficiary regarding my/our health plan as contemplated by both ERISA or PPACA, and that Healthcare Provider can pursue all rights that I/we may have under state and/or federal law regarding my/our health plan. This assignment, appointment, and designation will remain in effect unless revoked by me in writing. It is my intent that the effective date of this document shall relate back to include all services, supplies, test, treatments, or medications that have previously provided by Healthcare Provider. A photocopy or scan of this document is to be considered as valid and as enforceable as the original.

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctors office of any changes in my medical status. I also authorize the healthcare staff to perform the necessary services I may need.

We, at Trinity Integrated Health and Wellness Center, understand that sometimes you need to cancel or reschedule your appointments due to emergencies or obligations for work or family. If you are unable to keep your scheduled appointment, please notify us as soon as possible. However, when you do not call to cancel or reschedule your appointment, you are preventing another patient from getting much needed treatment.
To ensure that each patient is given the proper amount of time allotted for their visit and to provide the highest quality care, it is very important for each scheduled patient to attend their appointment on time. As a courtesy, a text reminder or call to you is made/attempted to remind you of your time appointment.

Effective September 1, 2023

If possible, please give us 24- hour notice if you need to cancel or reschedule your appointment. If your appointment is not cancelled and you simply fail to show up for your appointment more than once, you will be charged a $55.00 no show fee. It will be processed at the end of that business day to the card on file in your account. This $55.00 no show fee cannot and will not be billed to or covered by your insurance company.

Patients can call (318) 352-0099 or email trinityintergratedappointments@gmail.com If they need to cancel or reschedule their appointment.

Suggested Provider Statement of Patient/Client Rights and Responsibilities

• Patients/Clients have the right to be treated with dignity and respect.
• Patients/Clients have the right to fair treatment, regardless of race, ethnicity, creed, religious belief, sexual orientation, gender, age, health status, or source of payment for care.
• Patients/Clients have the right to have their treatment and other patient information kept private. Only by law may records be released without patient permission.
• Patients/Clients have the right to access care easily and in a timely fashion.
• Patients/Clients have the right to a candid discussion about all their treatment choices, regardless of cost or coverage by their benefit plan.
• Patients/Clients have the right to share in developing their plan of care.
• Patients/Clients have the right to the delivery of services in a culturally competent manner.
• Patients/Clients have the right to information about the organization, its providers, services, and role in the treatment process.
• Patients/Clients have the right to information about provider work history and training.
• Patients/Clients have the right to information about clinical guidelines used in providing and
  managing their care.
• Patients/Clients have a right to know about advocacy and community groups and prevention
  services.
• Patients/Clients have a right to freely file a complaint, grievance, or appeal, and to learn how to do so.
• Patients/Clients have the right to know about laws that relate to their rights and responsibilities.
• Patients/Clients have the right to know of their rights and responsibilities in the treatment process, and to make recommendations regarding the organizations rights and responsibilities.
• Patients/Clients have the responsibility to treat those who give them care with dignity and respect.
• Patients/Clients have the responsibility to give providers the information they need, in order to
  provide the best possible care.
• Patients/Clients have the responsibility to ask their providers questions about their care.
• Patients/Clients have the responsibility to help develop and follow the agreed-upon treatment
  plans for their care, including the agreed-upon medication plan.
• Patients/Clients have the responsibility to let their provider know when the treatment plan no
  longer works for them
• Patients/Clients have the responsibility to tell their provider about medication changes, including medications given to them by others.
• Patients/Clients have the responsibility to keep their appointments. Patients should call their
  providers as soon as possible if they need to cancel visits.
• Patients/Clients have the responsibility to let their provider know about their insurance coverage, and any changes to it.
• Patients/Clients have the responsibility to let their provider know about problems with paying fees.
• Patients/Clients have the responsibility to report fraud and abuse.
• Patients/Clients have the responsibility not to take actions that could harm others.
• Patients/Clients have the responsibility to openly report concerns about quality of care.
• Patients/Clients have the responsibility to let their provider know about any changes to their
  contact information (name, address, phone, etc.)
• Patients/Clients have the right and responsibility to understand and help develop plans and goals to improve their health.

I have read and understood my rights and responsibilities.

I hereby request and consent to the performance of chiropractic manipulation and manual therapy techniques and other chiropractic procedures, including various modes of physical therapeutic modalities and procedures and diagnostic X-rays, where warranted, on me (or on the patient named below, for whom I am legally responsible) by the doctor of chiropractic named below and/or other licensed doctors of chiropractic who now or in the future work at the clinic or office listed below.

I have had an opportunity to discuss with the Doctor of Chiropractic named below the nature and purpose of chiropractic adjustments and other procedures. I understand that the results are not guaranteed.

I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment and diagnostic services including but not limited to:
Manipulation: increased pain or discomfort, fractures, disc injuries, strokes, dislocations, and sprains.

Therapeutic Modalities and procedures: additional pain and discomfort. Endurance exercise may cause an increased risk of acute Myocardial Infarction (heart attack) in patients with known or possible cardiac conditions.

Radiographs: ionizing radiation can be harmful to a fetus for those who are pregnant or might be pregnant.

I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely upon the doctor to exercise judgement during the procedure which the doctor feels at the time, based upon the facts that is known to him or her, is in my best interest. The doctor named below has additionally explained the risks associated with my refusal of treatment.

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 for any future condition(s) for which I seek treatment.

AUTHORIZATION FOR USE/DISCLOSURE OF HEALTH INFORMATION

Authorization for Use/Disclosure of Information: I voluntarily consent to authorize my health care provider Trinity Integrated Health and Wellness Center to use or disclose my health information during the term of this Authorization to the recipient(s) that I have identified below.
Recipient: I authorize my healthcare information to be released to the following recipient(s):

Name: Trinity Integrated Health and Wellness
Address: 366 South Drive, Natchitoches, LA 71457
Phone: (318) 352-0099 Fax: (318) 352-1032

Information to be disclosed: I authorize the release of the following health information. All my health
information that the provider has in his or her possession, including information relating to any medical history, mental, or physical condition and any treatment received by me.

Refusal to sign/right to revoke: I understand that signing this form is voluntary and that if I do not sign, it will not affect the commencement, continuation or quality of my treatment at Trinity Chiropractic Clinic. If I change my mind, I understand that I can revoke this authorization by providing a written notice of revocation to the Trinity Chiropractic at the address listed above. The revocation will be effective immediately upon my health care providers receipt of my written notice, except that the revocation will not have any effect on any action taken by my health care provider in reliance on this Authorization before it received my written notice of revocation.

If individual is unable to sign this Authorization, please complete the information below:

MEDICARE limits chiropractic reimbursement to manual manipulation. Reimbursement is based on medically necessary correction care only; maintenance care is not covered. MEDICARE DOES NOT reimburse for charges of exams, x-rays, therapy, extremity adjusting, de-compression, acupuncture, supplements or any supplies such as topical analgesic gel, braces, pillows, etc. These services are the financial responsibility of the patient.

X-rays and/or an exam may be required to update your condition should a new course of treatment be initiated.

Medicare patients will be responsible for deductible amounts, all non-covered charges and possibly any denied visits which exceed Medicare guidelines.

Medicare supplemental policies and/or secondary policy benefits may be affected by Medicare denials.

Our office agrees to accept assignments from Medicare. You will be responsible for 20% co- insurance on the allowable charge for manual manipulation in addition to those charges not covered which are listed above.

In accordance with the Medicare Act. Section 1842(i), this letter is to advise you that Medicare
will only pay for services that it determines to be “reasonable and necessary” under Section 1862(a)(i) of the Medicare Act.

I have read and understand the limitations of my Medicare coverage and the effects it may have
on any supplement or secondary policies. I am aware that I will be responsible for any charges
that Medicare denies or deems over “reasonable and necessary”.

This questionnaire has been designed to give the doctor information as to how your neck pain has affected your ability to manage in everyday life. Please answer every section and mark in each section only ONE box which applies to you. We realize you may consider that two of the statements in any one section relate to you, but please just mark the box which MOST CLOSELY describes your problem.

This questionnaire has been designed to give the doctor information as to how your neck pain has affected your ability to manage in everyday life. Please answer every section and mark in each section only ONE box which applies to you. We realize you may consider that two of the statements in any one section relate to you, but please just mark the box which MOST CLOSELY describes your problem.