Instructions:

Please complete this entire packet to the best of your ability. Accurate information is necessary for us to provide the best care possible.

Please give yourself ample time to complete. It must be completed in one sitting. Typical time spent filling out this paperwork is 45 min to an hour.

All blanks MUST be filled in. If a section does not apply, please write in N/A or none. This ensures that we know a section was not missed in error. You will not be able to continue if there are any blank sections.

This paperwork needs to be completed prior to your scheduled appointment. Please complete prior to your appointment. If the paperwork is not complete by the time of your scheduled appointment, your appointment will be rescheduled.

If you have any questions you can call 206-824-5521 or email katelyn@vitalitychiropractic.com. If it is after hours, you may send an email to cami@vitalitychiropractic.com or text 206-395-5209 and Cami will reach out to you ASAP.

Your Auto Insurance Information

Other Parties Auto Insurance Information

Attorney's Information

If you have retained an attorney please fill out the information below. If you have not please fill the blanks with N/A.

I understand that if I do not provide all of the above information or provide it accurately it may result in Vitality Chiropractic not being able to bill the appropriate party. If I do not have have Personal Injury Protection (PIP) benefits, Un/Under Insured Motorist benefits, and have not retained an attorney to act on my behalf, I understand I will be responsible for paying for any balance that is accrued during my treatments at Vitality Chiropractic and obtaining reimbursement on my own.

From Birth to present, please list and describe: 

Please list below any and all symptoms you are experiencing since the incident:

Complete the following questions as it relates to how your injury/injuries affect your performance of everyday activities and/or work activity. Please circle the living or work duties that are painful or difficult for you to perform as a result of the injuries. Also circle the appropriate box designating reason for difficulty or limitation.

Please note: Vitality Chiropractic uses an automated text message reminder system. The patient can OPT-OUT of these reminders by replying 'STOP' at any time. If the patient opts out, and later wishes to opt back in please just request to do so with the Office Manager.

You are the decision maker for your health care. Part of our role is to provide you with information to assist you in making informed choices. This process is often referred to as “informed consent” and involves your understanding and agreement regarding the care we recommend, the benefits and risks associated with the care, alternatives, and the potential effect on your health if you choose not to receive the care.

Vitality Chiropractic recognizes the right of competent patients to decide whether to accept or reject proposed treatment/care and/or to decide on their treatment(s). When a patient is not competent, the right of informed consent is transferred to the person legally authorized medical proxy to make decisions on the patient’s behalf. Before exercising this right, we will provide patients with sufficient information to reach an informed decision. By signing you are stating that you are aware that you are agreeing to treatment and are aware that you can revoke consent at any time in writing after this form is signed. 

We will conduct some diagnostic and/or examination procedures during the initial visit and if indicated in the future. Any examinations or tests conducted will be carefully performed but may be uncomfortable. Please let us know at any time that the examination is painful or become intolerable.

Chiropractic care involves what is known as chiropractic adjustment. There may be additional supportive procedures or recommendations made. When providing an adjustment, hands or an instrument will be used to reposition anatomical structures, such as vertebrae. Potential benefits of an adjustment include restoring normal joint motion, reducing swelling and inflammation in a joint, reducing pain in the joint, and improving neurological functioning and overall well-being.

It is important that you understand, as with all health care approaches, results are not guaranteed, and there is no promise of a cure. As with all types of health care interventions, there are some risks to care, including, but not limited to: muscle spasms, aggravating and/or temporary increase in symptoms, lack of improvement of symptoms, including, but not limited to fractures (broken bones), disc injuries, strokes, dislocations, strains, and sprains. With respect to strokes, there is a rare but serious condition known as an arterial dissection that involves an abnormal change in the wall of an artery that may cause the development of a thrombus (clot) with the potential to lead to a stroke. This occurs in 3-4 of every 100,000 people, whether they are receiving health care or not. Patients who experience this condition often, but not always, present to their medical doctor or chiropractor with neck pain and headache. Unfortunately, a percentage of these patients will experience a stroke.  As chiropractic can involve manually and/or mechanically adjusting the cervical spine, it has been reported that chiropractic care may be a risk for developing this type of stroke. The association with stroke is exceedingly rare and is estimated to be related in one in one million to one in two million cervical adjustments.

It is also important that you understand there are treatment options available for your condition other than chiropractic procedures. Likely, you have tried many of these approaches already. These options may include, but are not limited to: self-administered care, over-the-counter pain relievers, physical measures and rest, medical care with prescription drugs, physical therapy, bracing, injections, and surgery. Lastly, you have the right to a second opinion and to secure other opinions about your circumstances and health care as you see fit. Our standard regarding informed consent is consistent with federal and state laws, rules, and regulations.

I voluntarily consent to treatment and diagnosis procedures provided by Dr. Bonnie Verhunce at Vitality Chiropractic. I am aware that Vitality Chiropractic does not diagnose or treat any disease or condition other than subluxation. However, if during your course of evaluation or treatment non-chiropractic or unusual findings are encountered, Dr. Bonnie will advise you. The only objective at Vitality Chiropractic is to eliminate a major interference to the full outward expression of your body's innate wisdom.

I consent to treatment being provided in an "open adjusting" environment. It is our practice, in this office, to provide chiropractic treatment in an open environment. This involves several patients being seen in the same room at the same time. Patients are within sight and earshot of one another. You acknowledge and consent to treatment in this setting and have been made aware that there is the potential for incidental disclosure of health information to other patients and staff within the adjustment area/office. If there is something that needs to be discussed with Dr. Bonnie in private, we ask that you let her know prior to the conversation so you may talk privately in the exam room.

I authorize Vitality Chiropractic to share my personal health information only with entities/persons directly related to my health care and my insurance and payment needs. Vitality Chiropractic is committed to protecting your personal health information.

I agree to be contacted via phone, text message, or email (or any combination of) with information related to my visits, such as an appointment reminder, check-ins, paperwork links or review requests. I understand that there is a potential for accidental disclosure of my private health information when using these methods. I understand that I can OPT OUT of the text message notifications by replying “Stop” or “Cancel”. Be aware that if you “opt out” you will no longer receive any appointment reminders and the office will no longer be able to communicate with you via the text messaging system. If you wish to opt out of one type of message, please email info@vitalitychiropractic.com and we can remove you from that specific list.

I consent to the use and disclosure of my protected health information for purposes of obtaining payment for services rendered by Dr. Bonnie and Vitality Chiropractic.

I acknowledge that Dr. Bonnie will be submitting claims to my insurance company on my behalf. I understand that any and all changes to my insurance coverage are my responsibility to notify Vitality Chiropractic. Furthermore, I understand the coverage is not a guarantee of payment. Payment is determined by the insurance’s claim adjustor assigned to my claim at the time the claim is received. All patients are responsible for non-covered services and for services rendered after insurance benefits have been exhausted. If the policy does not have Personal Injury Protection coverage, and there is no 3rd Party coverage, Vitality Chiropractic will bill my health insurance on my behalf. If the above stated insurances do not cover the cost of chiropractic services, I understand that I am responsible for providing payment to Vitality Chiropractic - unless another agreement has been made in writing (i.e., Letter of Protection from your attorney) - and that it is my responsibility to seek repayment from the responsible party, if possible.

I understand that it is Vitality Chiropractic’s policy and practice to utilize medical liens to ensure repayment of all third party and under/uninsured motorist claims pursuant under RCW 60.44.

I agree to place a credit card on file to be stored in a secure and tokenized system. I understand that it is my choice how Vitality Chiropractic processes the card that is placed on file, depending on how I fill out the Credit Card Payment Authorization Form. I understand that payment for treatments rendered is non-refundable.

I understand that there is a $25 cancellation fee, and agree to pay the fee, for any missed, canceled, or rescheduled exam, re-exams, or report of findings appointments where 24-hour notice is not given. This fee will be waived where required by law. This fee does not apply to an appointment where only an adjustment is provided.

• It is the intention of this office to assist the patient to make informed decisions about their healthcare and related costs. This process is accomplished through periodic financial conversations. It is the goal of this office to ensure that lines of communication are open so that every patient is aware of who in the office can assist with questions of a financial nature. This office recognizes that open and clear communication is particularly important for those patients with third-party assistance of any type. This office’s goal is to ensure that the financial relationship with our patients never interferes with the treatment relationship.

• For your convenience, this office accepts cash, checks, care credit and the following credit cards: Visa, MasterCard, American Express, Discover.

• Should payment be refused by your bank for any check written, this office will charge a fee of $35 to offset the charges we will incur as a result of the returned check.

• This office does not turn away any patient due to their ability to pay. If you feel you might qualify for our financial hardship policy, notify the office immediately so we can begin your qualification process.

• This office offers prompt payment discounts. We offer 10% off the actual fee when visits are set up on autopayment plan and 15% off when visits are prepaid by purchasing a package.

• It is our office policy that payment for services rendered is ultimately the responsibility of the patient, whether or not you have third party assistance with your financial obligation.

• It is the policy of this office to clearly communicate with each patient their financial responsibility, regardless of third-party assistance. This office implements this process beginning with the first contact a patient makes with this office. Per the No Surprises Act (NSA) effective January 1, 2022, we begin with verbally offering a Good Faith Estimate (GFE), in writing, for patients that are self-pay, uninsured, or opting not to use their health insurance. We follow the GFE delivery requirements included in this policy upon request. Once a new patient has been evaluated in the clinic, the provider will establish a treatment plan. This plan will be communicated to the patient and to the staff, who will then offer to the patient and deliver a Financial Report of Findings Good Faith Estimate when requested.  

• As a courtesy to our patients, this office will bill third party payers, accept assignment, and wait to be paid for some portion of our patients' financial responsibility.

• All patient copays are to be paid at the time of service.

• Patient deductible/coinsurances are to be paid after all remittances are received from the 3rd party payor and allocated to the patient account as such.

• Personal balances may not exceed $500 unless on a pre-arranged payment plan. Payment plans are available when balances exceed the patient’s ability to pay in full to ensure you are able to receive all the care you may require.

• The privilege of insurance assignment begins when our office receives and verifies your insurance information. Until that time, you are considered a “cash” patient and payment is expected at the time of service. As a courtesy to you, our office will pre-qualify your insurance coverage, in an effort to help you determine what coverage is available to you under your policy. We will help you make the best estimate of your coverage for the recommend services. This service is a courtesy to you and is not a guarantee of coverage or payment by the 3rd party payor.

• No one can predict what an insurance company will pay for the usual and customary charges for services rendered. If we participate on your plan, you will not encounter balance billing above the allowed/contracted rate as long as your benefits are effective/available. If we do not participate/are out of network, we can bill the insurance upon your request. If you do not have benefits available for chiropractic care we will work with you to help determine your cost of care.

• If your insurance has not paid on an assigned bill within 45 days, our staff looks into the claim for your by contacting the 3rd party payor for resolution. If it remains unpaid within 120 days the balance becomes due and payable immediately. If payment is received from the insurance carrier, resulting in a patient overpayment you will be refunded within 30 days to your original method of payment or via check if the original method was cash or no longer available.

• Most 3rd party payors, including most commercial insurance plans, Medicare, and PIP, only over what is medically necessary for a given condition, injury, and diagnosis. We can only bill 3rd party payors for such treatments. For patients who’s treatment is considered as maintenance, wellness or supportive care will be patient responsibility. Our office offers numerous payment options to allow you to continue care/treatment.

• Should you discontinue care for any reason, other than discharge by the doctor for a completed episode or care, any and all balances will become due and payable at that time. If you are on a predetermined payment plan, that plan will continue to be in effect until your balance is zero.

• If you have pre-paid for a package and wish to discontinue treatment/care, you can retain the balance for future care or you can request to be refunded the remaining balance.

MVA Claims ONLY

• If a patient is being seen for a Auto Accident / PIP Claim, we require all information of all insurance parties attached to the claim. If you are not at fault for an accident, and the other party does not have medical coverages on their policy, it is in your best interest to open a claim against  your insurance and obtain your benefits through your policy. If neither insurance has PIP/Med Pay benefits available, we are able to bill your health insurance.

• For MVA claims that are through Underinsured/Uninsured Motorist Coverage, a medical lien will be placed in effect until payment for full balance is received at the end of care.

• For MVA claims that are being held for 3rd party payment, a medical lien will be placed in effect until payment for the full balance is received at the end of care or settlement.

• In the event that coverages are not covered, denied, or go unpaid at the determination of the payor, patient will be finically responsible for all care/treatments.