Assignment, Release of Benefits and Guarantee of Payment
By clicking the button below, I certify that to the best of my knowledge the information on this form is accurate, truthful and current. I certify that I, and/or my dependent(s) have insurance coverage with the aforementioned company(s) and assign directly to Optimal Wellness for Life Chiropractic Center all insurance benefits, if any, otherwise payable to me for services rendered. I understand that 1) I am financially responsible for all charges whether or not paid by insurance and 2) I am financially responsible for any legal fees or other fees incurred by Optimal Wellness for Life Chiropractic Center for collection efforts of delinquent balances on my and/or my dependent(s) account(s). I authorize the use of my signature on all insurance submissions.Optimal Wellness for Life Chiropractic Center may use my healthcare information and may disclose such information to the above-named insurance company(s) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. The consent will end when my current treatment plan is completed or one year from the date below. I consent to treatment for myself and/or treatment of my minor dependent(s) and guarantee payment for all services rendered by Optimal Wellness for Life Chiropractic Center whether insurance pays or not.
Notice of Privacy Practices
I acknowledge that I have had the opportunity to review Optimal Wellness for Life Chiropractic Center’s "Notice of Privacy Practice" on the practice’s website online. I understand I have a right to review Optimal Wellness for Life Chiropractic Center’s Complete Notice of Privacy Practices prior to accepting this document. The Notice of Privacy Practices describes the types of uses and disclosures of protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Optimal Wellness for Life Chiropractic Center The Notice of Privacy Practices is also provided on request at the main administration desk of the practice. This Notice of Privacy Practices describes my rights and Optimal Wellness for Life Chiropractic Center’s duties with respect to my protected health information. Optimal Wellness for Life Chiropractic Center reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy to be sent in the mail, email or asking for one at the time of my next appointment.
Terms of Acceptance/Informed Consent
When we accept you as a patient it’s important that you understand the objectives of our care. Chiropractors provide a unique service that other healthcare providers do not offer. Chiropractors specialize in the location and correction of vertebral subluxations for the purpose of improving the health and function of your spine and nervous system. A vertebral subluxation is a misalignment or distortion of your spinal column and/or related structures that can affect your health and overall body functioning. Chiropractors spend years studying how to locate and correct this destructive condition. The correction is performed using specialized techniques called “chiropractic or spinal adjustments” over a period of time. When your spine is free of the nerve and musculoskeletal stress caused by subluxations your body can function more efficiently and your body’s natural ability to heal can work more optimally. It is not our objective to medically diagnose or treat any disease, symptom or condition. If you desire diagnosis or treatment for a specific symptom or treatment of a specific symptom, disease, or condition or advice on taking or stopping medications, we recommend you consult a healthcare provider who specializes in that area. If we discover unusual findings in the course of our chiropractic examination(s) we will let you know of them. You may then decide whether you wish to investigate further and discuss your healthcare options with other health professionals. Chiropractic, like all forms of health care, while offering considerable benefits may also provide some level of risk. This level of risk is most often very minimal. In very rare cases injury has been associated with chiropractic care. The types of complications that have been reported secondary to chiropractic care include sprain/strain injuries, irritation of a disc condition, and rarely, fractures. One of the extremely rare complications associated with spinal manipulation, occurring at a rate between one per one million to one per twelve million cervical spine (neck) adjustments is vertebral artery injury. This very rare occurrence could lead to stroke. Prior to receiving chiropractic care from Optimal Wellness for Life Chiropractic Center, a health history and physical examination will be completed. These procedures are performed to assess your specific condition, your overall health and, in particular, your spinal health. These procedures will assist us in determining if chiropractic care is needed, or if any further examinations or studies are needed. In addition, they will help us determine if there is any reason to modify your care or provide you with a referral to another health care provider. All relevant findings will be reported to you along with a recommended plan of care prior to beginning care. The purpose of chiropractic care is not to treat disease or conditions, nor to suppress symptoms, nor to perform surgery or prescribe medications but rather to improve the health and function of your spine and nerve system to help your body function at it’s optimum health and healing potential. It is our sole objective to improve and maintain the health and normal function of your spine and nerve system to the maximum degree possible for you.
Consent to Treatment, Payment Guarantee, and Release of Information
I hereby consent to examination and all treatments of myself or my minor dependent(s) for whom I am responsible. I guarantee payment for all services rendered regardless of my results or whether my insurance company(s) contributes or does not contribute toward payment for my care or care of minor dependent(s). I authorize Optimal Wellness for Life Chiropractic Center to release my health and personal information for the purposes of billing, insurance submission, doctor referrals, insurance requests, employer test results, governmental agencies, etc. as required by law and allowed by law.
Additional Consent to Treatment of Minor
I, the undersigned, being the parent and/or legal guardian of the above-referenced minor(s) consent to and request that he/she be examined, evaluated and treated at this office within the scope of Doctor of Chiropractic (D.C.) services rendered which may include but are not limited to x-rays, examinations, evaluations, diagnoses, and treatment as chiropractically indicated and/or are recommended or directed by our Doctor(s) of Chiropractic or other qualified staff of Optimal Wellness for Life Chiropractic Center
This consent shall be valid from this date forward until this applicable case is resolved or withdrawn by the undersigned. I, the undersigned, understand that I am responsible for, and agree to pay for any and all outstanding monies due for services rendered hereunder and understand that I must notify Optimal Wellness for Life Chiropractic Center IN WRITING of my intent to withdraw my consent.
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