1114 West Cook Road
Fort Wayne IN 46825
Office: 260-483-5588
Fax: 260-489-1819
Website: www.edgewoodchiropracticcenter.com
Email: edgewoodchiropractic@comcast.net

We are excited to provide the following services as we walk with you through your chiropractic journey.
IF you intend to utilize any insurance benefits, it is imperative that you verify coverage for the following services. Please call the member services number listed on your insurance card and ask if you plan covers chiropractic care. The questions below are a guide to assist you:

PLEASE NOTE: Benefit inquiries are not a guarantee of insurance coverage. Ultimately, you are financially responsible for any services rendered at any medical facility. In order to continue to accept insurance, ECC is requesting that all patients take an ACTIVE PART in all aspects of their health care coverage. *Please be advised that we are NOT in network with any Indiana Medicaid Plans and those plans obtained through the marketplace.*

Due to insurance company time filing constraints, ECC will FILE insurance claims for massage therapy but will no longer be filing pre-authorizations, treatment notes, plans of treatment, etc. with any insurance company.

Please tell us about your pregnancy:

THE NERVOUS SYSTEM CONTROLS AND COORDINATES ALL ORGANS AND STRUCTURES OF THE HUMAN BODY

Please check the corresponding boxes for each symptom or condition you have experienced - including both past and present

This office is required to notify you in writing, that by law, we must maintain the privacy and confidentiality of your Personal Health Information. In addition we must provide you with written notice concerning your rights to gain access to your health information, and the potential circumstances under which, by law, or as dictated by our office policy, we are permitted to disclose information about you to a third party without your authorization. Below is a brief summary of these circumstances. If you would like a more detailed explanation, one will be provided to you. Once you have read this notice, please sign and return to our front desk receptionist.

1. Treatment purposes - discussion with other health care providers involved in your care.
2. Inadvertent disclosures - open treating area mean open discussion. If you need to speak privately to the doctor, please let our staff know so we can place you in a private consultation room.
3. For payment purposes - to obtain payment from your insurance company or any other collateral source.
4. For workers compensation purposes - to process a claim or aid in investigation.
5. Emergency - in the event of a medical emergency we may notify a family member.
6. For Public health and safety - in order to prevent or lessen a serious or eminent threat to the health or safety of a person or general public.
7. To Government agencies or Law enforcement - to identify or locate a suspect, fugitive, material witness or missing person.
8. For military, national security, prisoner and government benefits purposes.
9. Deceased persons - discussion with coroners and medical examiners in the event of a patient's death.
10. Telephone calls or emails and appointment reminders - we may call your home and leave messages regarding a missed appointment or apprize you of changes in practice hours or upcoming events.
11. Change of ownership - in the event this practice is sold, the new owners would have access to your PHI.

1. To receive an accounting of disclosures.
2. To receive a paper copy of the comprehensive "Detail" Privacy Notice.
3. To request mailings to an address different than residence.
4. To request Restrictions on certain uses and disclosures and with whom we release information to, although we are not required to comply. If, however, we agree, the restriction will be in place until written notice of your intent to remove the restriction.
5. To inspect your records and receive one copy of your records at no charge, with notice in advance.
6. To request amendments to information. However, like restrictions, we are not required to agree to them.
7. To obtain one copy of your records at no charge, when timely notice is provided (72 hours). X-rays are original records and you are therefore not entitled to them. If you would like us to outsource them to an imaging center, to have copies made, we will be happy to accommodate you. However, you will be responsible for this cost.

If you wish to make a formal complaint about how we handle your health information, please contact our office. If you are still not satisfied with the manner in which this office handles your complaint, you can submit a formal complaint to:

DHHS, Office of Civil Rights 200 Independence Ave. SW Room 509F HHH Building Washington DC 20201

I have received a copy of Chiropractic's Patient Privacy Notice. I understand my rights as well as the practices duty to protect my health information, and have conveyed my understanding of these rights and duties to the doctor. I further understand that this office reserves the right to amend this 'Notice of Privacy Practice" at an time in the future and will make the new provisions effective for all information that it maintains past and present. I am aware that a more comprehensive version of this "Notice" is available to me. At this time, I do not have any questions regarding my rights or any of the information I have received.

We encourage and support a shared decision making process between us regarding your health needs. As a part of that process you have a right to be informed about the condition of your health and the recommended care and treatment to be provided to you so that you can make the decision whether or not to undergo such care with full knowledge of the known risks. This information is intended to make you better informed in order that you can knowledgably give or withhold your consent.

Chiropractic is based on the science which concerns itself with the relationship between structures (primarily the spine) and function (primarily the nervous system) and how this relationship can affect the restoration and preservation of health.

Adjustments are made by chiropractors in order to correct or reduce spinal and extremity joint subluxations. Vertebral subluxation is a disturbance to the nervous system and is a condition where one or more vertebra in the spine is misaligned and/or does not move properly causing interference and/or irritation to the nervous system. The primary goal in chiropractic care is the removal and/or reduction of nerve interference caused by vertebral subluxation.

A chiropractic examination will be performed which may include spinal and physical examination, orthopedic and neurological testing, palpation, specialized instrumentation.

The chiropractic adjustment is the application of a precise movement and/or force into the spine in order to reduce or correct vertebral subluxation(s). There are a number of different methods or techniques by which the chiropractic adjustment is delivered but are typically delivered by hand. Some may require the use of an instrument or other specialized equipment. Among other things, chiropractic care may reduce pain, increase mobility and improve quality of life.

In addition to the benefits of chiropractic care and treatment, one should also be aware of the existence of some risks and limitations of this care. The risks are seldom high enough to contraindicate care and all health care procedures have some risk associated with them.

Risks associated with some chiropractic treatment may include soreness, musculoskeletal sprain/strain, and fracture. In addition there are reported cases of stroke associated with visits to medical doctors and chiropractors. Research and scientific evidence does not establish a cause and effect relationship between chiropractic treatment and the occurrence of stroke; rather, recent studies indicate that patients may be consulting medical doctors and chiropractors when they are in the early stages of a stroke. In essence, there is a stroke already in process. However, you are being informed of this reported association because a stroke may cause serious neurological impairment.

I have been informed of the nature and purpose of chiropractic care, the possible consequences of care, and the risks of care, including the risk that the care may not accomplish the desired objective. Reasonable alternative treatments have been explained, including the risks, consequences and probable effectiveness of each. I have been advised of the possible consequences if no care is received. I acknowledge that no guarantees have been made to me concerning the results of the care and treatment.

I HAVE READ THE ABOVE PARAGRAPH. I UNDERSTAND THE INFORMATION PROVIDED. ALL QUESTIONS I HAVE ABOUT THIS INFORMATION HAVE BEEN ANSWERED TO MY SATISFACTION. HAVING THIS KNOWLEDGE, I KNOWINGLY AUTHORIZE THIS OFFICE TO PROCEED WITH CHIROPRACTIC CARE AND TREATMENT.

It is the policy of Edgewood Chiropractic Center that all services rendered are charged directly to you, the patient, and that ultimately the patient is responsible for all services, including those not reimbursed by your insurance or third-party payer. All Payments are due at the time of service, unless prior arrangements have been made. Our office accepts assignment with most insurance companies; however, insurance is not a guarantee of payment. Your insurance is an agreement between you and your insurance company. All insurance patients must pay their deductibles in full and copayments/coinsurance at time of service. If our office has not received payment by your insurance company within forty-five (45) days of our office submitting the claim, you will become responsible for payment in full. I, the undersigned, do hereby agree to be financially responsible for the entire balance due, including, but not limited to examinations, consultations, and/or treatments. I also acknowledge there will be a $35.00 fee for any checks returned due to insufficient funds. I understand that this service fee maybe in addition to any fees assessed by my financial institution. Furthermore, I agree that a late charge of 1.5% per month maybe assessed on any balance more than 30 days delinquent. In the event of any default in payment, I agree to pay all attorney fees and/or other collection costs necessary to collect on my delinquent account.

Due to the increased demand for massages and our limited space for our massage therapist we need to limit the frequency of massages to one per month. We will allow patients to schedule one massage per month no sooner than two months ahead. This will give every patient an opportunity to have a convenient time that will best suit his/her schedule.

We understand that situations arise in which you must cancel your massage appointment. It is therefore requested that if you must cancel your appointment, you provide at least 24-hour notice. This enables another patient who is waiting for a massage appointment to be scheduled in that appointment time. With cancellations made less than 24 hours prior, we are unable to offer that time to other patients.
We understand that certain unavoidable circumstances may not allow you to cancel with 24 hours. You may be subject to a $40.00 late cancellation fee in this instance. Late cancellation fees may be waived with approval of management only. ECC believes that a good massage therapist / patient relationship is based upon understanding and good communication.

Patients who do not show for his/her massage appointment will be charged a $40.00 No Show Fee. There is no exception to this fee. No show charges are the sole responsibility of the patient and cannot be billed to insurance. Any fees must be paid in full prior to the patients next appointment.

Completion of this form by a parent or guardian confirms consent for patients eighteen (18) and under to receive massage at Edgewood Chiropractic Center.

• Edgewood Chiropractic Center Massage Therapy Scheduling Policy
• Edgewood Chiropractic Center Cancellation Policy

• Edgewood Chiropractic Center No Show Fee Policy
• Edgewood Chiropractic Center Minor Policy