On a scale of 1 to 10 with 10 being the worst pain and zero being no pain, rate your above complaints by ticking the circle:
Consultation - includes practice member history (this service is complimentary)
Assessment (new or established practice member) - includes one or more of the following: thermography, surface electromyography, range of motion, motion and/or static palpation, leg check ($50-$100)
Chiropractic Adjustment - The actual re-alignment of the vertebra done by hand or instrument. Often a sound will be heard, but if there is no auditory result, it does not mean that the adjustment has not taken place ($40-$70)
X-Rays - Specific X-ray views taken of your spine to determine a misalignment/subluxation of your vertebrae. These can also be used to indicate progress after period of care. Cost is subject to insurance rate, otherwise $50 per view (per cervical, thoracic, lumbar) under compliance coupon.
I authorize and request payment of insurance benefits directly to Andres Julia, D.C. I agree that this authorization will cover all services rendered until I revoke the authorization. I agree that a photocopy of this form may be used in place of the original. All professional services rendered are charged to the patient. It is customary to pay for services when rendered unless other arrangements have been made in advance. I understand that I am financially responsible for charges not covered by insurance.
This office is required to notify you in writing, that by law, we must maintain the privacy and confidentiality of your Personal Health Information. In addition we must provide you with written notice concerning your rights to gain access to your health information, and the potential circumstances under which, by law, or as dictated by our office policy, we are permitted to disclose information about you to a third party without your authorization. Below is a brief summary of these circumstances. If you would like a more detailed explanation, one will be provided to you. In addition, you will find we have placed several copies in report folders labeled ‘HIPAA’ on tables in the reception. Once you have read this notice, please sign the last page, and return only the signature page to our front desk receptionist. Keep this page for your records.
COMPLAINTS:If you wish to make a formal complaint about how we handle your health information, please call Dr. Andres Julia at (727) 201-2271 if he is unavailable, you may make an appointment with our receptionist to see him within 72 hours or 3 working days. If you are still not satisfied with the manner in which this office handles your complaint, you can submit a formal complaint to:
DHHS, Office of Civil Rights 200 Independence Ave. SW Room 509F HHH Building Washington DC 20201
I have received a copy of Chiropractic’s Patient Privacy Notice. I understand my rights as well as the practices duty to protect my health information, and have conveyed my understanding of these rights and duties to the doctor. I further understand that this office reserves the right to amend this ‘Notice of Privacy Practice” at an time in the future and will make the new provisions effective for all information that it maintains past and present.
I am aware that a more comprehensive version of this “Notice” is available to me and several copies kept in the reception area. At this time, I do not have any questions regarding my rights or any of the information I have received.
CHIROPRACTIC CARE, WHILE OFFERING CONSIDERABLE BENEFITS, MAY ALSO PROVIDE SOME LEVEL OF RISK. IN EXTREMELY RARE CASES, INJURY HAS BEEN ASSOCIATED WITH CHIROPRACTIC CARE. THESE CASES INCLUDE: STRAIN/SPRAIN INJURIES, IRRITATION OF EXISTING DISC CONDITION, AND FRACTURES, ETC. ONE OF THE RAREST COMPLICATIONS ASSOCIATED WITH CHIROPRACTIC WHICH OCCURS AT A RATE BETWEEN ONE INSTANCE PER ONE MILLION TO TWO MILLION CERVICAL SPINE ADJUSTMENTS MAY BE A VERTEBRAL INJURY THAT COULD LEAD TO A STROKE.
PRIOR TO RECEIVING CHIROPRACTIC CARE IN THE OFFICE, A HEALTH HISTORY AND PHYSICAL EXAMINATION WILL BE COMPLETED TO ASSESS YOUR SPECIFIC HEALTH AND SPINAL NEEDS. THESE PROCEDURES WILL ASSIST US IN DETERMINING IF CHIROPRACTIC CARE IS NECESSARY OR IF FURTHER EXAMINATION IS 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 ALONG WITH A CARE PLAN PRIOR TO BEGINNING CARE.
I UNDERSTAND THERE ARE RISKS ASSOCIATED WITH CHIROPRACTIC CARE AND GIVE CONSENT TO THE EXAMINATION THE DOCTOR DEEMS NECESSARY AND CHIROPRACTIC CARE, INCLUDING SPINAL ADJUSTMENTS, AS REPORTED FOLLOWING MY ASSESSMENT.
TO PROMOTE THE MOST EFFECTIVE APPLICATION OF CHIROPRACTIC PROCEDURES AND THE STRONGEST POSSIBLE DOCTOR-PATIENT RELATIONSHIP, WE STATE THE FOLLOWING TO FACILITATE THE GOAL OF OPTIMUM HEALTH THROUGH CHIROPRACTIC. TO THAT END, WE ASK THAT YOU ACKNOWLEDGE THE FOLLOWING POINTS REGARDING SERVICES WE PROVIDE:
BY SIGNING BELOW, I AM STATING THAT I HAVE FULLY READ AND UNDERSTAND THE ABOVE STATEMENTS.
AS YOUR HEALTHCARE PROVIDER, WE ARE LEGALLY RESPONSIBLE FOR YOUR CHIROPRACTIC RECORDS. WE MUST MAINTAIN A RECORD OF YOUR X-RAYS IN OUR FILES.
X-RAYS ARE UTILIZED IN THIS OFFICE TO HELP LOCATE AND ANALYZE VERTEBRAL SUBLUXATIONS. HEALTH HISTORY AND EXAMS WILL ALLOW THE DOCTOR TO DETERMINE IF X-RAYS ARE NECESSARY FOR YOUR CASE. THESE X-RAYS ARE NOT USED TO INVESTIGATE FOR MEDICAL PATHOLOGY. THE DOCTOR(S) OF ABUNDANCE CHIROPRACTIC DO NOT DIAGNOSE OR TREAT MEDICAL CONDITIONS. HOWEVER, IF ANY ABNORMALITIES ARE FOUND, WE WILL BRING IT TO YOUR ATTENTION SO THAT YOU CAN SEEK PROPER MEDICAL ADVICE.
AT YOUR REQUEST, WE WILL PROVIDE YOU WITH A COPY OF YOUR X-RAYS.
THE FEE FOR COPYING YOUR X-RAYS ON A DISC IS $15.00 WHICH MUST BE PAID IN ADVANCE.
BY SIGNING BELOW I AM AGREEING TO THE ABOVE TERMS AND CONDITIONS
FEMALE PATIENTS ONLY: TO THE BEST OF MY KNOWLEDGE, I BELIEVE I AM NOT PREGNANT AT THE TIME X-RAYS ARE TAKEN AT ABUNDANCE CHIROPRACTIC