Patient Form

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 doctor’s office of any changes in my medical status. I also authorize the healthcare staff to perform the necessary services I may need.

In case of a medical emergency, if the patient is of school age 15+, it is ok to treat in my absence.

I hereby request and consent to the performance of examination, 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 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 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 judgment during the course of the procedure which the doctor feels at the time, based upon the facts then 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 and for any future condition(s) for which I seek treatment.

I understand and agree that (regardless of whatever health insurance or medical benefits I have), I am ultimately responsible to pay RESTORATIVE SPINE & JOINT as well as all employees, employers, representatives, and agents thereof, (hereinafter collectively referred to as “Healthcare 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 contract, PPACA governed plan/insurance contract) rights that I (or my child, spouse, or dependent) may have under my/our applicable health plan(s) or health insurance policy(ies). I also hereby appoint and designate that 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 result of services rendered by Healthcare Provider, and to pursue any and all remedies to which I/we maybe 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 and PPACA, and that Healthcare Provider can pursue any and 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 been previously provided by Healthcare Provider. A photocopy or scan or this document is to be considered as valid and as enforceable as the original.

ACKNOWLEDGMENT OF RECEIPT OF NOTICE
As required by HIPAA privacy regulations, I hereby acknowledge that I have been presented and have read a current copy of Restorative Spine & Joint NOTICE OF PRIVACY PRACTICES.

As required by HIPAA privacy regulations Restorative Spine & Joint has explained the NOTICE OF PRIVACY PRACTICES to my satisfaction. As required by the HIPAA privacy regulations, I am aware that Restorative Spine & Joint has included a provision that reserves the right to change the terms of its notice and make the new notice provisions effective for all protected health information that it maintains. I understand that this office is not required to honor any changes of the NOTICE OF PRIVACY PRACTICES.

Welcome to our office! Your health is our chief concern and we strive for excellence in chiropractic care. In order to make the handling of your financial obligations as smooth as possible, please read and sign the following policy. If you have any questions, our staff will be happy to assist you. 

General Insurance Information
Please remember that all health and accident policies are arrangements between you and the company that writes the policy. All charges in this office are your personal responsibility and all fees are charged directly to you. As a courtesy to you, we will prepare necessary insurance claim forms to assist in collections from your insurance company. We will also bill insurance on your behalf and will expect payment from them within 60 days. Should the claim remain unpaid over 60 days for any reason, we will then personally bill you for the balance, net 30 days. Please note that this office will not enter into dispute with an insurance company over your claim. 

Your coverage (PPO, HMO, EPO, HSA, etc)
This office is under contract with many insurance plans. Please present your insurance card to the front desk so that we may make a copy for your file. On your behalf, we will immediately begin verifying your estimated coverage. You will need to sign the Signature on File/Authorization form. Your financial obligation may consist of a co-payment and/or a deductible. The co-payment will be either a fixed amount or a percentage of the charges. Co-payments vary from plan to plan but generally range from $5.00 - $30.00 per visit. PLEASE NOTE THAT YOU ARE RESPONSIBLE FOR PAYMENT OF ALL FEES FOR PROFESSIONAL SERVICES EVEN THOUGH YOU MAY HAVE INSURANCE COVERAGE-this means that should the insurer fail to pay sums due, you are responsible for the payment.

Worker's Compensation
With authorization to treat from your employer, if you are hurt on the job your care is handled 100% through eligible worker's compensation benefits.

Personal Injury
This category also includes automobile accidents. If you have medical coverage (med-pay) on your auto insurance policy, we will bill them directly for prompt payment of your care. This coverage is in place to immediately handle your medical needs regardless of who is at fault. If you are not at fault, you will not be penalized by your insurance company as they will collect for reimbursement from the responsible party. If med-pay is not part of your coverage, we will set up monthly payment arrangements upon your request. Please remember, you are directly responsible for payment of your bill.

Medicare
We are happy to accept Medicare patients, and we accept Medicare assignment. You will receive our MEDICARE ADVANCECED BENEFICIARY NOTIFICATION. Please read and sign this form. We will be happy to answer any questions.

Personal Pay/Time of Service
Because of decreased administrative costs, we are able to extend a time of service (T.O.S.) discount to our patients who do not have or choose not to use their insurance. To receive this discount, services must be paid for at the time they were rendered. The discount will not apply if we must send a bill for payment. If you have any questions regarding this time of service discount, please speak to our office manager. For Example:

No Show Policy
It is important to our patients that we stay on schedule and make ourselves available to those patients in need with minimal or no wait time. To make this happen, we work hard to keep on schedule and many times have a waiting list for patients needing care. If you must cancel an appointment, we understand that things come up. A courtesy phone call is very important. A “no-show” takes an opportunity away from another patient who may be wanting to get in sooner. To that end, our office has implemented a “no-show” fee of $40.00 which will be paid in full prior to the next scheduled visit.

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I HAVE READ AND UNDERSTAND MY RESPONSIBILITY CONCERNING PAYMENT/POLICIES IN THIS OFFICE. I agree to be responsible for payments of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed upon dates, I understand that a 1-1/2% late charge (18% APR) may be added to my account and the time of service discount will become void. If required, I also understand a check of my credit history may be made. I agree to pay all costs of collection, including attorney fees should legal action be necessary.