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It is our desire that you have as pleasant an experience in our office as possible. Our most important concern is your health but we do need to do certain things to ensure that your personal injury bills will be taken care of. The following are a list of things all persons involved in an auto accident need to know about.
Please read the following and sign at the bottom of this form.
1. If the car is insured in MA: YOUR insurance company is responsible for paying your bills, NOT the company of the person who hit you. If the accident was someone else’s fault your insurance company will seek compensation from their insurance company. After the first $2,000.00 of total Personal Injury Protection (PIP) benefits are paid out, by law we must bill your health carrier. If your health carrier does not provide chiropractic benefit, or if you do not have health insurance your PIP company will continue to pay your bills up to a total of $8,000.00
2. It is YOUR responsibility to obtain the following information from your insurance company: Name, Address, Phone and Fax number, as well as the Claim number, Name and Extension of the PIP adjuster NOT the adjuster for the damage to your car.
3. Your insurance company will send you a form called a “PIP Application”. This form must be filled out by you as soon as it is received. Your insurance company will not pay your bills until this form is on file with them. Failure to send in your PIP Application will cause the bills to be your responsibility.
4. If you have decided to utilize the help of an attorney you and your attorney will need to sign a Lien form, which is held on file at this office. The Lien is used should you have any outstanding bills that are awaiting settlement to be paid.
5. At some point during your care, your insurance company will send you to another doctor for an evaluation. This is called an Independent Medical Examination (IME). Please inform this office immediately once you are notified of an IME.
6. Keeping your scheduled appointments is imperative, not only for your recovery but also to ensure your claims will be paid. If an insurance company sees you missing appointments or changing your treatment plan without the recommendation of your doctors, they will assume that you are recovered and no longer need care.
Please rate any symptom you have had since the accident. Skip those symptoms you have not experienced.
In consideration of the agreement of the facility and provider(s) named above to provide me with injury treatment services, I hereby to the extent of my treatment bills irrevocably assign to my healthcare facility and to my Provider(s) all my right, title and interest to and in all applicable insurance and indemnification reimbursement benefits of applicable insurance companies including but not limited to: Automobile PIP (Personal Injury Protection) coverage; Medical Payment Coverage, BI (Bodily Injury) liability proceeds and health care coverage to which I may be entitled to pay my Provider(s) for services rendered to treat me on and after the above date in connection with my injury or illness.
I further grant to my Provider an irrevocable Equitable Lien and an Official Legal Lien as set forth in Ch 111S70A through Ch111S70D Massachusetts General Laws to and in any insurance benefits that may be due me and I furthermore authorize my Provider(s) to provide my attorney and any applicable insurance companies involved with a full report concerning my condition and treatment, including but not limited to office notes, dates of visits, and charges incurred.
I hereby authorize and direct any and all applicable insurance companies to make immediate payment directly to my said Provider(s) for all benefits and sums due me that may be due him or her upon receipt by you of my Provider’s itemized statement for treatment services rendered to me.
It is further agreed that payment by any insurance company involved as herein directed to my Provider of any itemized statement shall be considered the same as if paid by the insurer directly to me.
I am aware that I remain personally responsible to my provider for the full amount of my unpaid treatment bills and further direct my Attorney representing me to withhold from the proceeds upon any final settlement or final disposition of my case an amount equal to that to pay any outstanding unpaid balance of my bills. This includes any balance due as a result of an independent medical exam that discontinued my personal injury protection benefits and/or my medical payments benefit.
Please read this consent form and discuss it, if you would like to, with your doctor, and then sign where indicated at the bottom of the page. Clinicians who use spinal manual therapy techniques, such as joint manipulation, mobilization, or adjustment are required to inform their patients that there may be some risks associated with such treatment.
Treatments provided at this clinic, including the spinal adjustment, manipulation and/or mobilization, have been the subject of much research conducted over many years and have been demonstrated to be appropriate and effective treatments for many common forms of spinal pain, pain in the shoulder/arms/legs, for headaches and other neuromuskulosketetal symptoms. Treatment provided at this clinic may also contribute to your overall well-being. The risk of injury or complication from manual treatment is substantially lower than the risk associated with many standard medical treatments given for the same forms of musculoskeletal pain, such as muscle relaxing drugs, anti-inflammatory drugs such as aspirin, or pain pills. The most frequent risk that occurs in a chiropractic clinic is from burns associated with hot packs. Our office does not even use hot packs. Rarely some patients have reported muscle or ligament sprains or strains or rib fractures following an adjustment, however, our low amplitude techniques make that extremely improbable. There have been some “reports” of disc injury following an adjustment, however, there is NO scientific study that has ever demonstrated that such injuries are caused, or may be caused, by adjustments or manipulative techniques. In fact there is much scientific evidence to the contrary. Chiropractic adjustments offer disc patients significant relief and a speedier recovery without the need to resort to surgery. There have also been “reports” of injuries to a vertebral artery following neck adjustments. Usually these patients have a predilection for vertebral artery dissection prior to their chiropractic visit. These patients are already at risk for stroke under many positional activities. They are already at risk for serious neurological injury and impairment, and are no more likely to have such an incident in a chiropractic office than they are in a medical clinic or a beauty salon. This form of complication is astronomically rare occurring about 1 in 12-50 million and has little or no correlation with the chiropractic adjustment.
Your clinician will evaluate your individual case; provide an explanation of care and a suggested treatment plan, or alternatively a referral for outside consultation and/or further medical evaluation if deemed necessary.
Acknowledgement: I acknowledge that I have read, discussed, or have been given the opportunity to discuss, with my clinician the nature of chiropractic treatment in general and my treatment in particular as well as the contents of the consent.
Consent: I consent to the chiropractic treatment(s) offered or recommended to me by my clinician, including joint adjustment or manipulation or mobilization to the joints of the spine (neck and back), pelvis and extremities (shoulder, upper limbs and lower limbs). I intend this consent to apply to all my present and future treatments at this clinic.
PERMISSION TO COMMUNICATE (HIPAA)
We are very concerned with protecting your privacy, especially in matters that concern your personal health information. In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). We are required to supply you with a copy of our privacy policies and procedures. We encourage you to read this document carefully, for it outlines the use and limitations of the disclosure of your health information and your rights as a patient. If you ever have and questions or concerns regarding the use of dissemination of your personal health information, we would be happy to address them.
AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION (HIPAA)
I hereby authorize Dr. Debs or his assigned staff members to release information contained in my medical record to any and all insurance carriers from whom I may be due benefits, to my primary care physician or other healthcare providers associated with my treatment, to the state chiropractic society in the event their assistance is needed on my behalf, and to my attorney of record (if an attorney is involved).
Due to high patient demand, and limited availability of appointment we have instituted a $25.00 NO SHOW FEE. You must give 24 hour notice to cancel appointments. Failure to do so may result in a $25.00 fee charged to your account.
I agree to give 24 hours notice to cancel an appointment. IF notice is not given I understand that there is a $25.00 fee incurred for each occurrence.
I HEARBY CERTIFY that I have read and understand the conditions of this agreement for Professional/Privacy/Financial Services.
I acknowledge that I have been offered a copy of inBalance Chiropractic & Wellness’ Notice of Privacy Practices for Protected Health Information.