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  • BUSINESS ARRANGEMENT POLICY

  • We are committed to providing you with the best possible care. If you have health insurance, we are here to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance, and your understanding of our payment policy.


    Many times the expenses incurred by an individual for health care are paid by insurance companies. Recognizing this, it is our policy to accept assignment for health care rendered to our patients under the following circumstances.

    1. Personal or Group Health Insurance: it is the office policy to collect the portion of the bill that your insurance company does not pay at time of service, i.e. co-pay/deductible.


             a. If Underwood Chiropractic LLC is not a network provider for your            insurance company,you will be responsible to pay any outstanding balances not paid by your insurance company.

    2. Medicare Patients: Medicare will only reimburse for spinal adjustments. Any extra spinal care, which may include extremity adjusting, ART, or supportive modalities, i.e. ultrasound/E-Stim, is the patient’s financial responsibility and payment is due at time of service.

    3. Auto Accident/Insurance Coverage: Partial to complete credit with chiropractic insurance coverage. Patient responsible for payment and may seek financial reimbursement pending settlement.


    4. Work Injury/Compensation Coverage: With employer authorization, partial to complete credit.

    We must emphasize that as health care providers, our relationship is with you, not your insurance company. While the filing of insurance claims is a service that we perform for our patients, all charges are your responsibility from the date services are rendered.

    If there is no health insurance coverage which reimburses you for our services, arrangements will be made with you that will allow you to receive the needed care and take care of expenses on a daily, weekly, or monthly basis.

    We sincerely believe that the best doctor/patient relationship exists when there is complete understanding of treatment and financial responsibilities between the doctor and the patient. Please feel free to ask for clarification on any policies that you do not understand.

    Signature below is only acknowledgement that you have read and received this Business Arrangement Policy.

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  • Appointment Cancellation Policy

  • We strive to render excellent chiropractic care to you and the rest of our patients. In an attempt to be consistent with this, we have an Appointment Cancellation
    Policy that allows us to schedule appointments for all patients. When an
    appointment is scheduled, that time has been set aside for you and when it is
    missed, that time cannot be used to treat another patient.

    Our policy is as follows:

    We require that you give our office 24 hours notice in the event that you need to
    reschedule your appointment; this allows for other patients to be scheduled into
    that appointment. If you miss an appointment (Monday—Friday) without contacting our office within the required time, this is considered a missed appointment and a fee of $65.00 will be charged to you. No future appointments can be scheduled nor can records be transferred without the payment of
    this fee.

    Additionally, if a patient is more than 15 minutes late without prior notice for a
    scheduled appointment, we will consider this a missed appointment and the
    $65.00 cancellation fee will be charged.

    ***APPOINTMENTS CANNOT BE RESCHEDULED OR CANCELLED VIA TEXT
    REMINDER SYSTEM

    If you have any questions regarding this policy, please let our staff know and we
    will be glad to clarify any questions you have.

    We thank you for your patronage.

    I have read and understand the Appointment Cancellation Policy of the practice and I agree to be bound by its terms. I also understand and agree that such terms may be amended from time-to-time by the practice.

  • I, * (print name), have received a copy of Underwood
    Chiropractic’s Cancellation Policy.

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  • Financial Disclosure Form

  • I understand that Underwood Chiropractic’s financial policy states “Fees are due and payable at the time of services”. I understand the Fees as stated below:

    The Initial Visit Fee is $99.00, and includes the following items:

     Consultation
     Physical Examination
     Regional Exams
     Report of Findings with Treatment Recommendations

    ___________________________________________________________

     

    Other services and fees:

    Medical Reevaluation (Child/Adult) $75.00/$85.00
    Spinal Manipulation (Child/Adult) $45.00/$65.00
    Rehabilitation/Exam (Child) $45.00/$75.00
    Rehabilitation/Exam (Adult) $65.00/$85.00

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  • CONSENT TO CHIROPRACTIC CARE

  • I hereby request and consent to the performance of chiropractic adjustments, Active
    Release Technique therapies or other chiropractic/medical procedures on me or on *by Dr. Scott R. Underwood, D.C., and/or other licensed doctors of
    chiropractic who may be employed by or engaged in practice in the Underwood Chiropractic. I have had an opportunity to discuss with Dr. Scott R. Underwood, D.C., or other clinic personnel the nature and purpose of chiropractic adjustments and other procedures. I understand that the practice of neither chiropractic nor medicine is an exact science and that my care may involve the making of judgments based upon the facts known to the doctor at the time; that it is not reasonable to expect the doctor to be able to anticipate or explain all risks and complications; that an undesirable result does not necessarily indicate an error in judgment; that no guarantee as to results has been made to nor relied upon by me, and I wish to rely on the doctor to exercise judgment during the course of the procedure which he/she feels at the time, based upon facts then known, is in my best interests. I have also been advised that although the incidence of complications associated with chiropractic services is very low, anyone undergoing adjusting or manipulative procedures should know of possible complications, which have been alleged. These include but are not limited to: fractures, disk injuries, strokes, dislocation, sprains, minor soreness and those which relate to physical aberrations unknown or reasonably undetectable by the doctor. I have read or have had read to me the above Consent. I have also had an opportunity to ask questions about its contents, and by signing below, acknowledge my understanding of its contents.

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  • HIPAA Notice of Privacy Practices

    Underwood Chiropractic, LLC 787 Sunset Blvd. Suite 200 O’Fallon, IL 62269 (618) 624-2400 Fax: (618) 624-2407
  • THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

  • This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

     

    1. Uses and Disclosures of Protected Health Information

    Uses and Disclosures of Protected Health Information
    Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.

    Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we
    would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the
    physician has the necessary information to diagnose or treat you.

    Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

    Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

    We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required By Law, Public Health issues as required by law, Communicable Diseases: Health Oversight:
    Abuse or Neglect: Food and Drug Administration requirements: Legal Proceedings: Law Enforcement: Coroners, Funeral Directors, and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Workers’ Compensation:
    Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section
    164.500.

    Other Permitted and Required Uses and Disclosures Will Be Made Only With Your Consent, Authorization or Opportunity to Object unless required by law.

    You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

  • Your Rights
    Following is a statement of your rights with respect to your protected health information.

    You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

    You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

    Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.

    You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.

    You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

    You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.

    We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

    Complaints

    You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate
    against you for filing a complaint.

    Release of Information

    I hereby authorize Underwood Chiropractic to release and/or discuss any and all information pertaining to my medical records, billing, and insurance with below listed person(s). I am revoke/amend this Release at any given time by completing and signing a new HIPPA to be kept on file.

     

  • We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number.


    Signature below is only acknowledgement that you have received this Notice of our Privacy Practices:

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  • This notice was published and becomes effective on/or before April 14, 2003.

  • UNDERWOOD CHIROPRACTIC

    NEW ADULT PATIENT HISTORY INTAKE
  • To our new patients: Welcome to the Chiropractic practice of Dr. Scott R. Underwood. To help us establish you with our practice, please provide us with your complete health history.

     

    Personal History

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  • Current Medication
                              

    Dose
                            

    Times / Day                           

  • Current Herbs / Vitamins/ Supplements
                              

    Dose
                            

    Times / Day  
                            

  • PERSONAL AND FAMILY HISTORY

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  • SOCIAL HISTORY

    (check those that apply):
  • Children (list sex/ages)

  • LIFESTYLE / SELF-CARE ISSUES

  • In order to offer you the best care, we need to understand your general health status. Please answer the following questions by checking the boxes as indicated:

    C Current: Currently has this condition

    P Previously: Had the condition in the past but does not have any problem now

    N Never: Never had the condition

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  • HEALTH SCREENING HISTORY

  • List the date of your most recent test or exam.

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  • This history record has been designed to facilitate our patients continuity of care at Underwood Chiropractic. This is a confidential record and will be kept in this facility. Information contained here will not be released to anyone without your authorization to do so.

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