Thank you for selecting our health care team! We strive to provide you with the highest quality care in a comfortable atmosphere. To help us meet all your health needs, please fill out the following forms to the best of your ability. If you have any questions or need assistance, please ask us – we will be happy to help you.

PATIENT

SPOUSE OR GUARDIAN

PLEASE READ CAREFULLY

I understand and agree that health and accident insurance policies are an arrangement between and insurance carrier and myself. Furthermore, I understand that KANADY CHIROPRACTIC CENTER INC. will prepare any necessary reports and forms to assist me in making collections from the insurance company, and those collections will be credited to my account on receipt. However, I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered me will be immediately due and payable.

Legal guardian’s signature authorizing payment and care of a minor.

HEALTH HISTORY

DAILY HABITS

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices is NOT an authorization. This Notice of Privacy Practices describes how we, our Business Associates and their subcontractors, may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health condition and related health care services.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to a physician to whom you have been referred, DME vendors, surgery centers/hospitals, referring physicians, family practitioner, physical therapists, home health providers, laboratories, worker comp adjusters and nurse case managers, etc. to ensure that the healthcare provider has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay, surgery, MRI or other diagnostic test, injection procedures, injection series, physical therapy, etc., may require that your relevant protected health information be disclosed to your health plan to obtain approval for the procedure.

Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment, employee review, training of medical students, licensing, fundraising, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment, and inform you about treatment alternatives or other health-related benefits and services that may be of interest to you. If we use or disclose your protected health information for fundraising activities, we will provide you the choice to opt out of those activities. You may also choose to opt back in. We may use or disclose your protected health information in the following situations without your authorization. These situations include: as required by law, public health issues as required by law, communicable diseases, health oversight, abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, funeral directors, organ donation, research, criminal activity, military activity and national security, workers’ compensation, inmates, and other required uses and disclosures. Under the law, we must make disclosures to you upon your request. Under the law, we must also disclose your protected health information when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements under Section 164.500.

USES AND DISCLOSURES THAT REQUIRE YOUR AUTHORIZATION

Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization or opportunity to object unless required by law. Without your authorization, we are expressly prohibited to use or disclose your protected health information for marketing purposes. We may not sell your protected health information without your authorization. We may not use or disclose most psychotherapy notes contained in your protected health information. We will not use or disclose any of your protected health information that contains genetic information that will be used for underwriting purposes.

You may revoke the authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

YOUR RIGHTS
The following are statements of your rights with respect to your protected health information.
You have the right to inspect and copy your protected health information (fees may apply) – Pursuant to your written request, you have the right to inspect or copy your protected health information whether in paper or electronic format. Under federal law, however, you may not inspect or copy the following records: Psychotherapy notes, information compiled in reasonable anticipation of, or used in, a civil, criminal, or administrative action or proceeding, protected health information restricted by law, information that is related to medical research in which you have agreed to participate, information whose disclosure may result in harm or injury to you or to another person, or information that was obtained under a promise of confidentiality.

You have the right to request a restriction of your protected health information – This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to your requested restriction except if you request that the physician not disclose protected health information to your health plan with respect to healthcare for which you have paid in full out of pocket.

You have the right to request confidential communications – You have the right to request confidential communication from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.

You have the right to request an amendment to your protected health information – If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures – You have the right to receive an accounting of disclosures, paper or electronic, except for disclosures: pursuant to an authorization, for purposes of treatment, payment, healthcare operations; required by law, that occurred prior to April 14, 2003, or six years prior to the date of the request.

You have the right to receive notice of a breach – We will notify you if your unsecured protected health information has been breached.

You have the right to obtain a paper copy of this notice from us even if you have agreed to receive the notice electronically. We reserve the right to change the terms of this notice and we will notify you of such changes on the following appointment. We will also make available copies of our new notice if you wish to obtain one.

COMPLAINTS
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our HIPAA Compliance Officer of your complaint. We will not retaliate against you for filing a complaint.

HIPAA COMPLIANCE OFFICER: Lynn Kanady (907) 272-2700 Kanady@gci.net 

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. We are also required to abide by the terms of the notice currently in effect. If you have any questions in reference to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number.

Please sign below. Please note that by signing this form you are only acknowledging that you have received or been given the opportunity to receive a copy of our Notice of Privacy Practices.

Financial Policy

1. I understand and agree that health and accident insurance policies are an arrangement between the insurance carrier and myself.
2. I understand that Kanady Chiropractic Center will prepare any necessary reports and forms to assist me in making collection from the insurance company and that amount authorized to be paid directly to Kanady Chiropractic Center will be credited to my account upon receipt.
3. I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment.
4. I also understand that if I suspend or terminate my treatment any and all fees for professional services rendered to me will be immediately due and payable.
5. I understand Kanady Chiropractic Center files insurance claims as a COURTESY. In no way does it relieve myself from the responsibility of payment.
6. Kanady Chiropractic Center will send me a statement via mail each month. I fully understand that if I am not regularly making payments that Kanady Chiropractic Center reserves the right to charge a $5 service fee. In the case of Personal Injury claims we will assess a monthly service fee if the insurance carrier does not make timely payments.
7. Kanady Chiropractic Center is willing to work with you and make payment arrangements if needed. It is imperative, however, that payments of an agreed upon amount be made every month. In the case of an emergency and disruption of payment, please contact our office immediately.
8. If my insurance does not authorize my visits or considers them not medically necessary, I understand I will be responsible for payment.

READ CAREFULLY AND SIGN NAME BELOW

AUTHORIZATION TO RELEASE MEDICAL INFORMATION:
I authorize release of medical information necessary to process this (these) insurance claim(s) to any insurance company, attorney, or adjuster and permit the following to be used in place of this original document for all federal, state, commercial, compensation, or liability insurance claims: a photocopy of other facsimile reproduction of this authorization, or

1. use of a computer to indicate my signature is on file at office, and/or
2. use of a computer to electronically transmit my claim for processing

AUTHORIZATION TO ASSIGN MEDICAL BENEFITS TO OFFICE:
I certify that information provided relative to injury, illness, and insurance coverage is both true and correct. I certify that I have updated this office of any new injuries, accidents, or changes in my health history, address,telephone number or insurance coverage since my last visit. I authorize payment of insurance benefits or proceeds from any liability claim and legal/court settlement to be assigned to the chiropractors of this office to the extent that their charges are paid in full.

ACKNOWLEDGEMENT OF INSURANCE LIMITATIONS:
Many insurance carriers require a written referral in advance of service. Patients, parents, or the guardians are responsible for (1) obtaining necessary referrals and (2) contacting their insurance carrier to verify benefits in advance of service. I understand and agree that health and accident insurance policies are an arrangement between and insurance carrier and myself. I understand that I am fully responsible for noncovered services, deductibles, co-insurance, and any penalties imposed by my insurance company on any chiropractor for seeing patients out-of-network. Co-payments are due at time of service. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.

ACKNOWLEDGEMENT OF PAYMENT RESPONSIBILITY:
Payment for chiropractic services is between the office (chiropractor) and the patient. I authorize this office and its staff to examine and treat my condition as the chiropractor sees fit. I understand and agree that all services rendered to me will be charged to me and I’m responsible for timely payment, in full, of such services. Therefore, I understand that this office cannot accept responsibility for collecting or negotiating settlement on any disputed (1) health insurance claim, (2) worker's compensation claim, (3) accidental injury/illness liability claim, (4) claim where patient is/will be represented by an attorney, and/or (5) claim to be settled in a court of law.