Is this concern affecting any of the activities below?
Payment in full is expected in all FIRST VISIT services. All other fees are to be paid at time of service unless other arrangements have been made and agreed upon in writing.
**The cash fee for a new patient is $150.00, which includes the first consult, a chiropractic exam, a report of findings, and the first adjustment**
If your insurance company covers Chiropractic care and you would like us to assist you in the billing process, please fill out the “Insurance Permission” section below.
As a courtesy to you we will bill your insurance company. If payment is not received after 30 days, you should contact your insurance company and have them make payment. If, after 60 days, payment is still not received, you will be responsible for payment. We need your permission with respect to the following two statements or we cannot make claims directly to your insurance company:
“I authorize Community Chiropractic to release to my insurance company any medical or other information necessary to process my insurance claims.”
“I authorize payment be made directly to Community Chiropractic. I permit a copy of this authorization to be used in place of the original.”
Also, if you are not the subscriber on your health insurance policy, please provide the following subscriber information which is important for looking up medical benefits information and in the claims submission process. Thank you.
The following office procedures allows Community Chiropractic of Acton to operate in an efficient manner and allow us to support our practice members/patients with their care. By signing below you are giving us authorization to follow through with these procedures. Should you desire something not be done, please let us know.
You have the right to refuse any part of this authorization without affecting your care or the relationship with anyone at Community Chiropractic of Acton.
This authorization may be revoked by you at any time. Revocation may be accomplished by advising us in writing of your desire to withdraw your authorization. Please allow a reasonable processing time for the change in our system to be completed.
We at Community Chiropractic of Acton 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 practice member/patient. If you ever have any questions or concerns regarding the use or dissemination of your personal health information, we would be happy to address them.
I acknowledge that I have received a copy of Community Chiropractic of Acton Notice of Privacy Practices for Protected Health Information.
Your e-signature below indicates your authorization of these activities. This notice is effective as of the date below and expires seven years from the date you last received services in this office.
When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective. It is important that each patient understand both the objective and the method that will be able to attain it. This will prevent any confusion or disappointment.
The objective of chiropractic health care in this office is to improve and optimize the health and wellbeing of the spine and nerve system through the correction of Vertebral Subluxations.
Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body’s innate ability to express its maximum health potential.
Our chiropractic method of correction of a vertebral subluxation is by specific adjustments of the spine. An adjustment is the specific application of forces made by hand or with an adjusting instrument. We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal evaluation, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others.
Outcomes and options relative to care have been discussed and noted. All questions regarding the doctor’s objectives pertaining to my care in this office have been answered to my complete satisfaction.
I therefore accept chiropractic care on this basis.