This is the expanded version of the abbreviated authorizations and agreement for the following:

• Health Information Privacy and Protection Act (HIPPA)
• Patient contact Agreement
• Insurance Assignment and Agreement
• Informed Consent for Chiropractic Care and Adjustments

Health Information Privacy and Protection Act (HIPPA)

We are very concerned with protecting your privacy.  While the law requires us to give you this disclosure, we understand that we have, and always will, respect the privacy of your health information.


There are several reasons for having to use or disclose your PHI (personal health information)
We may have to disclose to another healthcare provider or hospital should we refer you to them for a diagnosis, assessment, or treatment of health condition.
We may have to disclose PHI and/or billing records to another party if they are potentially responsible for the payment of your services.
We may need to use your PHI within our practice for quality control or other operational purposes.


You have the right to request that we do not disclose your health information to specific individuals, companies or organizations.  If you would like to place any restrictions on the use or disclosure of your PHI, we will respectfully request that you submit these restrictions in writing.  With your right to restriction, you also have the right to revoke your authorization or consent to us at any time.  Again, this change of authorization is requested in writing before your file status will be changed.

In general, the HIPPA privacy rule gives individuals the right to request a restriction on uses and disclosures of the PHI.  The individual is also provided the right to request confidential communications, such as reminder appointment times, follow up of health care, insurance coverage’s/benefits issues or any other information that only the patient will personally be able to answer.

Patient Contact Agreement

All patient contact is done via e-mail; this includes, but is not limited to: welcome letter, thank you letters, birthday cards, monthly newsletters, promotions, and necessary updates.  All monthly billing is also done via e-mail through PayPal. It is not required that you pay through PayPal, instead you may mail a check, call in your credit card information or drop by the office at any time.  We respect your e-mail box space and privacy, we will do our best to limit the number of e-mail that we send and we will never sell or give out our e-mail list.  You are also welcome to unsubscribe from the e-mail list at any time.
Please notify if you do not have email access and we will continue to send paper copies of all relevant promotions, events and/or office information.  

INSURANCE ASSIGNMENT AND AGREEMENT

I hereby instruct and direct my insurance company to pay by check made payable and mailed directly to:

For professional or medical expense benefits allowable and otherwise payable to me under my current insurance policy as payment towards the total charges for the professional services rendered.  This payment will not exceed my indebtedness to the above mentioned assignee and I agree to pay, in a current manner, any balance of said professional financial policy of the above assignee.  This assignment is to be considered by me or any other party until such time that all the above doctor’s fees are paid in full.

As a courtesy, our office accepts insurance assignment, upon verification of your benefits and coverage.  We gladly file all claims for services, according to our policies, directly to your insurance carrier.

• You will be responsible for any/all deductibles, co-insurance/payments, and non-covered benefits, which we will gladly provide several options to help you take care of these out of pocket expenses.
• We will do our best to accurately file your claims; however, we cannot be responsible for how your insurance company chooses to reimburse for your care, even if it is different that the benefits they quoted to us during the verification process.
• Should your carrier deny any claims, we will provide the necessary documents for a valid appeal or reconsideration.  However, if this endeavor is not successful, you will be responsible for you account balance, and we will be glad to provide you with available payment options, at said time.  It will then be your responsibility to pursuit reimbursement directly from your insurance company.
• If your care requires an authorization from your Primary Care Physician or insurance carrier, we will do our best to maintain these authorizations for treatment.  However, it is your responsibility to take an active role in the authorization process, and stay updated on their dates of expiration.  We will not assume responsibility for any unauthorized treatment; your involvement increases the likelihood of obtaining full coverage.
•  Although insurance coverage varies depending on individual contracts and plans, we have found that most Plans do not provide coverage or benefits for the following services:
  • -Rehabilitative, maintenance, or chiropractic wellness care
  • -Supports, braces, off the shelf chiropractic pillows, and most supplies
  • -Nutritional supplements

INFORMED CONSENT TO CHIROPRACTIC CARE AND ADJUSTMENTS

I have been informed that it is not uncommon that patients have some increased discomfort after an adjustment.  If that happens I will apply ice to the area and rest it.  If I am concerned about this discomfort or develop any new symptoms, I will call the office for same day emergency attention.  If I am out of town or unable to contact the doctor, I can present myself to an emergency room.
If any test were performed outside of this office (Laboratory or other diagnostic procedures) I understand that the doctor will notify me of the results at my next scheduled appointment.
I hereby consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physiotherapy, by the doctor of chiropractic or anyone working in this clinic authorized by the doctor of chiropractic.
I understand the nature and purpose of chiropractic adjustments and other procedures.  I understand that results are not guaranteed.
I further understand and am informed that, as in all health care, in the practice of chiropractic there are some very slight risks to treatment including, but not limited to; muscle sprain/strain, disc injuries, and strokes.  I do not expect the doctor to be able to anticipate and explain all risks and complications, therefore I am relying on the doctor to exercise judgment during the course of the procedure which the doctor feels is in my best interest, based on the facts known at the time.
I understand that this consent covers the entire course of treatment for my present condition and for any future condition for which I seek treatment.