I VERIFY AND ACKNOWLEDGE THAT ALL INFORMATION IS CURRENT AND CORRECT (PLEASE SIGN BELOW).

On the arrow diagram above:

What are your health goals?

• $30 charge for 1 Hour massage
• $15 charge for 30 min massage
• $10 charge for Chiropractic Adjustment
• $10 charge for Laser
• $10 charge for Spinal Decompression

All payments will be processed to the credit card on file that same day. Late arrivals to sessions may require to be shortened in order to accommodate others whose appointments follow yours. Depending upon how late you arrive, your therapist will then determine if there is enough time remaining to start a treatment. Regardless of the length of the treatment actually given, you will be responsible for "full cost" of the cost of that session. Out of respect and consideration for your therapist and other customers, please plan accordingly and be on time.

I authorize the release of any medical information necessary to process my claim and/or for better treatment in this office including x-rays, MRIs, Lab tests, etc.

 

It is my responsibility to know what services are covered by my insurance plan. I have reviewed carefully the section in my insurance coverage booklet that describes the coverage of benefits for the services that will be provided at this office. I will call my plan administrator with any questions. I will pay for any services I receive that are not covered or denied by my insurance plan.

I will provide full and accurate insurance information in advance of my appointment, or will pay for the appointment on a self-pay basis. I will present my insurance card at the time of my appointment. I will provide updated insurance information promptly in the case of any changes.

I understand that I, not my insurance company, am responsible for full payment of my fees. I understand that insurance billing is provided by my healthcare provider as a courtesy, but I remain the responsible party.

I understand that, all reimbursements paid to me will be promptly forwarded (within 10 days) to Greenway Cotton Chiropractic to be applied to my charges in arrears.

I understand that, if after 90 days my insurance company has not responded I will receive a statement. I agree to pay my balance in full at that time. I understand that I will be reimbursed promptly if and when the insurance payment arrives.

I understand that, if my account is referred to a collection specialist due to nonpayment, I will pay any applicable collection fees.

I understand that, "Authorization to Pay the Doctor" I hereby authorize payment directly to Greenway/Cotton Chiropractic of the insurance benefits otherwise payable to me.

I understand that, Personal Injury/Auto Claim, Non Personal Injury/Auto Claim in the case that I choose Non Personal Injury/Auto Claim, I state that I was not involved in any auto accident or personal injury caused by any other party. I further state that my diagnostic test or treatment is not the result of an injury while on the job or by any other person related to my employment.

I understand that, In the case of auto carrier or workman's compensation claims, whether settled or unsettled, I understand that I am responsible for all costs of chiropractic care which become payable within 30 days after the end of treatment and am held to the same rules as mentioned in the balance held policy noted above.

I understand that I am solely responsible for any and all missed, canceled or reschedule appointment fees whether the charges are in relation to an auto case or otherwise. I understand that my credit card will be charged at the time of the occurrence, if I am unable to give proper notice of more than 24 hours prior to my schedule appointment.

Dispute Procedure

In the event of a dispute between myself and Greenway/Cotton Chiropractic whether for charges, procedures or balances I owe, I hereby waive the statute of
limitations on collections and/or recovery. I also understand that litigation is certain once balances owed reaches 120 days past due, and I agree to pay all litigation
costs incurred by Greenway/Cotton Chiropractic as a result of inaction to timely payment of my account. I understand and agree to pay a 50% collection fee on any
outstanding balances due that are turned over to a collection agency.

HIPAA Privacy Rule
Consent for Purposes of Treatment, Payment and Healthcare Operations
I acknowledge that Greenway/Cotton Chiropractic “Notice of Privacy Practices Abridged Edition” has been provided to me.
I understand I have a right to review the entire Greenway/Cotton Chiropractic Notice of Privacy Practices prior to signing this
document. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur
in my treatment, payment of my bills or in the performance of health care operations of Greenway/Cotton Chiropractic. The Notice of
Privacy Practices for Greenway/Cotton Chiropractic also, is provided on request at the main administration desk of this practice. This
Notice of Privacy Practices also describes my rights and Greenway/Cotton Chiropractic duties with respect to my protected health
information.
Greenway/Cotton Chiropractic reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I
may obtain a revised notice of privacy practices by calling the office and requesting a revised copy be sent in the mail or asking for one at
the time of my next appointment.

PATIENT ACKNOWLEDGEMENT
By signing my name below, I acknowledge receipt of the above stated notice and my understanding and agreement to its terms.

 I give authorization to the following individuals listed below to

Informed Consent to Chiropractic & Massage Services
 I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various
modes of physical therapy, massage therapy and diagnostic X-rays, on me (or on the patient named below, for whom I am legally
responsible) by the licensed doctor of chiropractic who now or in the future work at the clinic or office listed below or any other
office or clinic.
 I consent to the opportunity to discuss with the doctor of chiropractic or with other office or clinic personnel 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,
including but not limited to fractures, disc injuries, strokes, dislocations and sprains. 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.
 I hereby consent to massage therapy to be performed by affiliate Massage Therapist within the office and acknowledge that if I
experience any pain or discomfort within the massage session
 I have read, or have had read to me, the above consent. I consent to the 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 will immediately inform the therapist so that the
pressure and/or strokes may be adjusted to my level of comfort.
 I further understand that Massage Therapy should not be construed as a substitute for medical examination, diagnosis, or
treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of
which I am aware.
 Because Massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical
conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and
understand that there shall be no liability on the therapist’s part should I fail to do so.
 Cupping/Gua Sha: I understand that cupping therapy will leave bruise-like marks that will last several days depending on the
severity of my condition. While most marks fade and disappear after a few days, there are times when marks could take up to 15
days to clear and in rare cases, it has been reported that marks have taken up to 21 days to fully clear.
o Contraindications: 1. Hemophilia or other bleeding/clotting disorders 2. Patients taking blood thinners 3. Weak patients or
those who have been ill 4. Abdomen and lower back on pregnant women 5. Diabetics. Especially those with uncontrolled
blood sugar as they may not be able to feel pain properly 6. Those who are unable to experience heat or pain properly 7.
Those who have circulatory conditions 8. Those who are unsure if their condition is contraindicated should seek
guidance from their primary care physician prior to receiving cupping therapy.
o I understand that bruising, discoloration and/or soreness will likely occur following this treatment and may take days or
weeks to fully resolve. I further understand that the above-listed conditions are contraindicated for cupping therapy and I
have informed my therapist/physician of any and all medical conditions, even those not listed as contraindications. I further
understand that there is a potential for burns and/or blisters due to the fire/heat aspect of the treatment. This is a rare but
not unexpected occurrence. 
 Improper Conduct: This is a Therapeutic Massage session and any sexual remarks or advances will terminate the session and
understand I will be liable for payment of the scheduled treatment. I understand the Massage Therapist practitioner reserves the
right to refuse services to me for any reason that the Therapist deems necessary. Male and female modest will be considered will not
be exposed or touched at any time. Professional draping will be used for your privacy and comfort. Our policy requires therapists to
leave the room prior to disrobing/undressing and use draping with sheets/ blankets at all times during every massage session.

Consent to Treatment of a Minor: By my signature below, I hereby authorize the spa and its therapists to provide massage and related services to my minor child or dependent as we deem necessary. Additionally, I have read, verified, and agree with all information on this form. I understand that I may be present during any massage received by child. This authorization is valid until and unless it is revoked by me in writing

Patient Options Access Program (Free Patient Enrolment)

As a patient, you are a participant in a Discount Managed Care Organization provided by Patient Options. There is NO FEE for patients to participated,
and it is provided free to the public for this who are uninsured or otherwise underinsured. The agreement its terms and conditions are between you and
Patient Options. The Agreement is and shall continue for a period of 12 months from the date of signature below and are electronically enrolled at
www.PatientOptions.org. by your Provider and shall continue as stated for 12 months from date of signature below. You will automatically be reenrolled
for successive one year 12 months unless written request to cancel from Patient Options enrollment.
 There are NO FEE’s, Charges, or other considerations required for participation.
Disclosures
 The program provides discounts to you from contracted healthcare providers for services rendered
 The program participant is obligated to pay for healthcare services directly to de facto 3rd party provider but will received a
contractual discount from the healthcare providers who is contracted with Patient Options
 This is NOT insurance qualified policy under the Affordable Cares Act or any state regulated program. Patient agrees to the
program and the discounts offered by contracted Providers are not available in instances where another third party insurance
company is responsible for charges.
 Patient absolves provider of wrongdoing in the event the patient chooses to bill insurance for discounted services under this
agreement.
 The name and address of the Discount Managed Care Organization is :
Patient Options
9435 Waterstone Blvd. Suite: 140.
Cincinnati, Ohio 45249
(866) 275-5633
 This disclosure and its benefit description represent the entire agreement between you and Patient Options and supersedes all other
prior representations, statements, or written agreements between you and Patient options.
I have read and agree to the terms and conditions set forth above: