New Patient Questionnaire- Child (12 or Younger)

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.

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.