The chiropractic doctor provides a specialized, non-duplicating health care service which includes detecting and correcting spinal subluxations (a misalignment of one or more vertebrae causing a blockage in nerve flow). It is important to note that the chiropractic doctor cannot diagnose, treat or cure any disease, although the doctors of Health From Within Family Wellness Center are more than happy to work with other types of providers in your health care regimen.
I do hereby authorize the doctors of Health From Within Family Wellness Center to administer such chiropractic care that is necessary for my particular case. This may include consultation, examination, adjustments or any other chiropractic procedure, which is advisable and necessary for my healthcare. I shall have an opportunity to discuss all chiropractic care that shall be necessary for my particular case. The doctor, of course, will not give any treatment or care if he is aware that such care may be contra-indicated, however, it is the responsibility of the patient to make it known, or to learn through healthcare procedures whatever he/she is suffering from: latent pathological defects, illnesses or deformities which would otherwise not come to the attention of the chiropractic doctor. I acknowledge that no guaranties can be made with respect to my treatment, and regardless of the outcome, I shall be responsible for all costs associated with my care.
In considering the amount of chiropractic expenses to be incurred, I, the undersigned, have insurance and/or employee health care benefits coverage, and hereby assign and convey directly to Health From Within Family Wellness Center, all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for services rendered from such doctor and clinic. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize the doctor to release all medical information necessary to process this claim. I hereby authorize any plan administrator or fiduciary, insurer and my attorney to release to such doctor and clinic any and all plan documents, insurance policy and/or settlement information upon written request from such doctor and clinic in order to claim such medical benefits, reimbursement or any applicable remedies. I authorize the use of this signature on all my insurance and/or employee health benefits claim submissions.
I hereby convey to the above named doctor and clinic to the full extent permissible under the law and under the any applicable insurance policies and/or employee health care plan any claim, chose in action, or other right I may have to such insurance and/or employee health care benefits coverage under any applicable insurance policies and/or employee health care plan with respect to medical expenses incurred as a result of the medical services I received from the above named doctor and clinic and to the extent permissible under the law to claim such medical benefits, insurance reimbursement and any applicable remedies. Further, in response to any reasonable request for cooperation, I agree to cooperate with such doctor and clinic in any attempts by such doctor and clinic to pursue such claim, chose in action or right against my insurers and/or employee health care plan, including, if necessary, bring suit with such doctor and clinic against such insurers and/or employee health care plan in my name but at such doctor and clinic’s expenses.
INTEREST AND COLLECTION: I acknowledge and agree that, should my account become more than thirty (30) days overdue, I will incur interest on my past due balance of seven percent (7%) per annum. I further acknowledge and agree that Health From Within Family Wellness Center shall be entitled to reimbursement from me for any legal costs, including attorney fees, for all efforts to collect on any past due account with Health From Within Family Wellness Center.
This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I have read and fully understand this agreement.
I understand that Health From Within Family Wellness Center has video recording equipment in the office for training purposes and to ensure that I receive the best possible care and experience. By signing below, I give permission to Health From Within Family Wellness Center to video record my office visits. I shall have the option to revoke my consent upon giving written notice to the Office Manager.
I have been informed that upon request I can receive a copy of the privacy practices (HIPPA). I am aware that I have an opportunity to discuss my rights to privacy if I please.
Additional Terms of Acceptance
We are committed to you, and helping you and your family to understand your health condition. In order to achieve this, the following is our policy regarding going over your x-ray results. Should the doctor determine & your test reveal that you have subluxation, nerve damage or dysfunction, or degeneration (or any other serious conditions on your x-rays), YOUR SPOUSE will be required to attend the immediately next scheduled doctor’s visit to discuss your exam/x-ray findings. This is for your own safety and benefit, as we believe that it is crucial to have family support to help with your health.
Additionally, it is important to have your spouse in attendance due to vital nature of what will be discussed, including but not limited to the following:
- Treatment choices and options.
- Insurance or other financial arrangements.
- Supportive home care.
Having your spouse in attendance will also prevent having to go over an x-ray/exam finding more than one time per patient, preventing unnecessary work and minimizing charges and costs to you. The Doctor is willing to contact any employers for excused absence needs. Your cooperation is appreciated.
Consent to Evaluate and Treat a Minor:
I, being the parent or legal guardian of the patient, have read and fully understand the above terms of acceptance and hereby grant permission for my child to receive chiropractic care.
This is to certify that to the best of my knowledge I am NOT pregnant and the above and doctor and his/her associates have my permission to perform an x-ray evaluation. I have been advised that x-rays can harm a fetus (unborn child) in the early stages.