What percentage of your day (at home or work) do you:
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+ Other Pain
What makes it ...
Patients at our office are seen by appointment and every effort will be made to keep that appointment time with you. Should your appointment time need to be rescheduled or canceled, we will require a 24 hour prior notice to the scheduled appointment time, except in the case of emergency. Additionally, if you are 5 or more minutes late to your scheduled appointment you may be asked to reschedule. These policies allow other patients needing care adequate time to fill your appointment as we do not double book out of respect for your time.
You are allowed 1 late cancellation at no charge. On the second occurrence, you will be charged the appointment fee of $50 that is due prior to any subsequent treatment. If you should miss a third scheduled appointment, you will be dismissed from care. This will reset every 10 visits.
The office number for Balanced Body Soft Tissue & Spine is (515) 963-1641. Phone calls for appointments are answered during regular office hours (please see website for current hours). If we are unable to answer the telephone, you may leave us a message on the answering machine and we will return your call as soon as possible.
Insurance & Reimbursement Issues
In-network insurance claims will be filed for you, provided you supply the office with a copy of your current insurance card. We will make every effort to assist you with verifying the chiropractic health benefits (not imaging, physical therapy, etc) that are covered by your insurance. Regardless of coverage, the financial responsibility for our services rests with you and you will be responsible for any remaining balance 60 days after it has been submitted by our office. Please familiarize yourself with the chiropractic benefits package of your particular policy to avoid this. Insurance benefits are always based on their definition of medical necessity, if you are under maintenance care there will be a separate out-of-pocket fee.
Payment (including co-payments, deductibles and co-insurance) are expected the day the services are rendered. We accept all major credit cards, cash or check. If your insurance overpays we will issue a prompt refund.
Please read this entire document before signing it. It is important that you understand the information contained in this document. Please ask questions before you sign it if there is anything that is unclear.
The Nature of the Chiropractic Adjustment, Manual Adhesion Release (MAR) and Instrument Adhesion Release (IAR).
The primary treatments Balanced Body Soft Tissue & Spine uses are spinal manipulative therapy and manual or instrument-assisted adhesion release. These procedures will be used to treat you whether it may be by hand or via a hand-held mechanical instrument. When your joints are adjusted, you may feel a sense of movement and it may cause an audible ‘pop’ or ‘click’, much as you have experienced when you ‘crack’ your knuckles. With adhesion release you may experience discomfort similar to that of a deep tissue massage in a more localized region.
As part of the analysis, examination, and procedure you are consenting to the following procedures: postural analysis, vital signs, range of motion testing, muscle strength testing, basic neurological testing, orthopedic testing, palpation, spinal & extremity manipulative therapy, MAR, IAR and any other modalities or tests that may be relevant to your condition.
Contra-Indications to Care
Where vertebral subluxations or soft tissue adhesions are detected, the treatments in this office are usually beneficial and seldom cause any adverse reactions. In rare cases, undetected physical defects, deformities, or pathologies may render the patient susceptible to injury. I will make every reasonable effort during the examination to screen for contraindications to care; however, if you are aware that you are suffering from: pathological conditions, illnesses, injuries, or deformities, it is your responsibility to inform me.
The Material Risk Inherent in the Chiropractic Adjustment
As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation and soft tissue therapies. These complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, cervical myelopathy, costovertebral strains and separations. These complications are general described as rare. Some types of manipulations of the neck have been associated with injuries to the arteries of the neck leading or contributing to serious complications including stroke. Stroke has been the subject of tremendous disagreement; the incidences are exceedingly rare and estimated to occur between one in one million and one in five million cervical adjustments. More commonly, patients may feel some stiffness and soreness following the first few days of treatment as their body accommodates to therapy and on occasion bruising. Due to the complexities of medical conditions and the many variables that can affect a patient’s response, no specific results or guarantees can be promised or implied. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may grant or withhold your consent for procedures described to you for the treatment of your condition.
The Availability and Nature of other Treatment Options
Other treatment options for your condition may include:
If you choose to use one of the above noted “other treatment” options, you should be aware that there are risks and benefits of such options and you may wish to discuss these with your primary medical physician.
Risks and Dangers Attendant to Remaining Untreated
Remaining untreated may allow the formation of adhesions and reduced mobility, progression of symptoms, and deterioration of your condition which may reduce your functioning and overall health, promoting degeneration in these areas. Over time this process may complicate treatment, making it more difficult and less effective the longer it is postponed.
Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have a right to adequate notice of the uses and disclosures of your protected health information ("PHI") that may be made by this medical practice. PHI is information about you, including demographic information, that may identify you and that relates to your past, present, or duties of this practice with respect to your PHI. This notice describes your PHI may be used and disclosed and how you can get access to this information.
Uses & Disclosures of Protected Health Information: Your PHI may be used and disclosed by your physician, our office staff and other 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 your physician’s practice, and any other use required by law.
Treatment: We will use and disclose your PHI to provide, coordinate, or manage your health care and any related services.
Payment: We may need to disclose information about the treatment, procedures or care at our practice provided to you in order to bill and receive payment for services we provided. We may share this information with you, an insurance company or any third party responsible for payment.
Healthcare Operations: In order to help us run our practice more efficiently and provide better patient care, we may use and disclose your PHI to business entities who need to use or disclose your information to provide a service for our medical practice.
You have the following rights with respect to your personal health information:
Right to Receive Personal Health Information Confidentially. You have the right to receive confidential communications of your PHI by alternate means or locations.
Right to Inspect and Copy. You have the right to inspect and copy your medical record that has been created to treat you and is used to make decisions about your care. This includes medical and billing records
Right to Amend. If you think there is information in your record that may be inaccurate or incomplete, you have the right to request an amendment or clarification of information in your record.
Right to Restrict Uses and Disclosures. You have the right to request restrictions on how our practice makes certain uses and disclosures of your personal health information for treatment, payment or healthcare operations.
Right to an Accounting of Uses and Disclosures. You have the right to receive an accounting of the disclosures of your personal health information that our practice makes for purposes other than treatment, payment or healthcare operations.
Right to Copy of Notice. You have the right to obtain a copy of our notice of privacy practices summary (or original document if you feel the summary is inadequate)upon request at any time. Please call us at 515-963-1641for a copy or ask for a copy at the reception desk.
Changes to this Notice. Our practice is required to abide by the terms of this notice, which is currently in effect. We reserve the right to change the terms of this notice and to make the new notice provisions effective for all personal health information we already have about you and may obtain in the future. If we change our notice, we will post notice of this change thirty (30) days prior to making the change effective. Notice change will be placed in our reception area at the front desk and web site.
Practice Contact. If you would like more information about this notice, please contact Dr. Hommer a t 515-963-1641. If you have any complaints regarding our privacy practices, please address your complaint to Dr. Hommer in writing.
Complaints. If you believe your privacy rights may have been violated or you become aware of a privacy concern you would like to report to our practice. Please note, all concerns or complaints regarding your personal health information are important to our practice. There will be no retaliation against you for filing a complaint with our office.
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.