Describe your symptoms and how they began:
5. How bad are your symptoms at their:
12. What do you hope to get from your visit/treatment:
What is your height and weight?
My height is feet feet and inches inches. My weight is lbs lbs
For each of the conditions listed below, place a check in the Past column if you have had the condition in the past. If you presently have a condition listed below, place a check in the Present column.
Indicate if an immediate family member has had any of the following:
List all prescription and over the counter medications, and nutritional/herbal supplements you are taking:
List all the surgical procedures you have had and times you have been hospitalized:
Your Protected Health Information (PHI) will be used by this office or disclosed to others for the purposes of treatment, obtaining payment, or supporting the day‐to‐day health care operations of this office. You should review the Notice of Privacy Practices for a more complete description of how your PHI may be used or disclosed. It describes your rights as they concern the limited use of health information, including your demographic information, collected from you and created or received by this office. You may review the Notice prior to signing this consent. You may request a copyof the Notice at the Front Desk. This office reserves the right to modify the Privacy Practices outlined in the Notice.
Requesting a Restriction on the Use or Disclosure of Your Information: You may request a restriction on theuse or disclosure of your PHI. It is the policy of this office that it will continue to provide treatment for a patient who restricts consent to the use anddisclosure of his/her PHI for the purposes of treatment, payment, or health care operations. Use or disclosure of protected information in violation ofan agreed upon restriction will be a violation of the federal privacy standards.
Revocation of Consent: You may revoke this consent to the use and disclosure of your PHI. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review itcarefully.
You have the right to:
• Get a copy of your paper or electronic medical record• Correct your paper or electronic medical record• Request confidential communication• Ask us to limit the information we share• Get a list of those with whom we’ve shared your information• Get a copy of this privacy notice• Choose someone to act for you• File a complaint if you believe your privacy rights have been violated
You have some choices in the way that we use and share information as we:
• Tell family and friends about your condition• Provide disaster relief• Include you in a hospital directory• Provide mental health care• Market our services and sell your information• Raise funds• We never sell or market names of other data.
Our Uses and Disclosures
We may use and share your information as we:
• Treat you• Run our organization• Bill for your services• Help with public health and safety issues• Do research• Comply with the law• Respond to organ and tissue donation requests• Work with a medical examiner or funeral director• Address workers’ compensation, law enforcement, and other government requests• Respond to lawsuits and legal actions
Your RightsWhen it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record
• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, costbased fee. Ask us to correct your medical record• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.• We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.• We will say “yes” to all reasonable requests. Ask us to limit what we use or share• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.• If you pay for a service or health care item out‐of‐pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information. Get a list of those with whom we’ve shared information• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost‐based fee if you ask for another one within 12 months. Get a copy of this privacy notice. You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.• We will make sure the person has this authority and can act for you before we take any action.File a complaint if you feel your rights are violated• You can complain if you feel we have violated your rights by contacting us using the information on page 1.• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200Independence Avenue, S.W., Washington, D.C. 20201, calling 1‐877‐696‐6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.• We will not retaliate against you for filing a complaint.
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information inthe situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
• Share information with your family, close friends, or others involved in your care• Share information in a disaster relief situation• Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
• Marketing purposes• Sale of your information• Most sharing of psychotherapy notes
In the case of fundraising:
• We may contact you for fundraising efforts, but you can tell us not to contact you again.
How do we typically use or share your health information?
We typically use or share your health information in the following ways.
We can use your health information and share it with other professionals who are caring for you.Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization
We can use and share your health information to run our practice, improve your care, and contact you when necessary.Example: We use health information about you to manage your treatment and services.
Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities.Example: We give information about you to your health insurance plan so it will pay for your services.
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health andresearch. We have to meet many conditions in the law before we can share your information for these purposes. For more information see:www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
We can share health information about you for certain situations such as:
• Preventing disease• Helping with product recalls• Reporting adverse reactions to medications• Reporting suspected abuse, neglect, or domestic violence• Preventing or reducing a serious threat to anyone’s health or safety
We can use or share your information for health research.
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests
We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests
We can use or share health information about you:
• For workers’ compensation claims• For law enforcement purposes or with a law enforcement official• With health oversight agencies for activities authorized by law• For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a subpoena.
• We are required by law to maintain the privacy and security of your protected health information. Our privacy officer is Merrick Fisher, DC.• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.• We must follow the duties and privacy practices described in this notice and give you a copy of it.• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you maychange your mind at any time. Let us know in writing if you change your mind.• We comply with Texas HB300, which is an expanded version of HIPAA specific to the State of Texas.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available uponrequest, in our office, and on our web site.
Merrick Fisher, DC, Kristin Weikel, DC, EP-C 4818 Berkman Dr., Suite 100 Austin, TX 78723P: 512.505.8500 F: 512.592.7153
Welcome to Whole Family Chiropractors. We are pleased you have chosen us for your health and wellness needs. At our clinic we treat you as an individual. Beyond treating specific injuries, we customize your therapy to meet broader health goals, striving to offer treatment that enhances your overall wellness.
Our practice began as a Chiropractic practice and has since expanded to include various physical medicine therapies including trigger point release and myo-fascial and myo-therapy as core services. Please understand that though you may find similarities between massage and this therapy; there is a significant difference. Our therapists are specially trained and directed by Dr. Fisher on your specific case with targeted goals in mind. Again, this is not massage therapy but rather part of your chiropractic coordination of care designed to speed the healing process and lead to stability.
Our staff works to make your experiences at our office pleasant, efficient and beneficial. Since we schedule to be ready for you at your specific time, we ask that you please be on time for your appointment. A routine office visit is 15 minutes in length. We understand that some circumstances require more time; for example, a new injury or extreme pain. If you think you may require a longer appointment, please ask the office staff to schedule accordingly. Occasionally, we need to treat an emergency that takes longer than we have anticipated. If we are running behind, we ask for your patience and understanding. If you have a serious time-crunch, please let us know and we will try to accommodate your schedule.
If you are unable to keep your scheduled appointment, please let us know as soon as possible so we may schedule another person who needs our services into that time slot. Since we may have a waiting list, a late cancellation means someone else missed out on an appointment. We also want to help you keep your treatment plan active and effective. We will always make time to see you even if you are late, you just may need to wait a short time. There is a 24-hour cancellation policy for myo-therapy appointments. Less than 24 hours will be charged a $105 late-cancellation fee. If you are late for your therapy appointment you will be charged for the full time you have scheduled. A missed therapy appointment will be charged $105. It is our policy to collect for therapy at the time of scheduling. If you fall behind in payments, your therapy appointment may be cancelled. We are not able to extend discounts nor payment plans for therapy services.
Our holistic approach to healthcare includes awareness that, in some cases, you may need a specialty that we do not offer. We can refer you to physicians with a like-minded commitment to consider you as the whole person you are. In some cases, to facilitate your recovery or optimal health, we may determine that co-management of your cases is the best choice. It is also not uncommon for us to seek a second opinion. We are committed to insuring you the most efficacious treatment and if there is a specialist that may be able to provide additional insight for us, we will ask for a consult. Additionally, the doctor may recommend a specific diagnostic or screening tests; it is your responsibility to schedule them and / or follow up with your PCP. I.e. abnormal blood pressure.
We know you have a choice in health care, and we are committed to exceeding your expectations. Please let us know if there is anything we can do to make your visits with us more comfortable.
We request payment at the time of services rendered. A 1.5% interest will accrue and be assessed monthly to accounts 30 days past due. Accounts are delinquent at 45 days and are subject to a continuing compounded interest each month or collections. Whole Family Chiropractors reserves the right to charge reasonable collections for attorney’s fees to all delinquent accounts. Financial arrangements are subject to renewal at the start of each new year. Should changes arise in your medical or financial situation that would affect your current financial agreement, you must notify our office prior to your next appointment. Should you discontinue care or be released from further service at our office, all outstanding balances will be due. Our office accepts cash, checks, and all major credit cards. Exceptions to this policy are detailed below. If you have a genuine financial hardship, please let us know and we will consider reducing fees or offering a payment plan to assist with the hardship.
If you have an outstanding balance after 2 weeks, and not have scheduled another appointment or made prior arrangements with our staff, you authorize Whole Family Chiropractors to charge the credit card previous given for any and all remaining balances.
This office is currently in-network with Medicare, BCBSTX, Humana, Aetna, Friday and Seton Health Care. In many cases, as a courtesy to you, we will bill your insurance company. To do this, we will require an assignment of benefits to allow us to be paid directly by your insurance company. Our contract with these insurers mandates that from the patient we collect plan deductibles, copays and/or co-insurance as per the individual policy and this office agrees to electronically submit charges for all services performed. For all other insurance policies, we charge our regular fees, and as a courtesy, will submit bills to the insurance company for consideration. If the policy does offer out-of-network chiropractic benefits, and the deductible is $1500 or less, we will submit bills to the insurance company. We will also agree to collect the policy deductible, copay and/or co-insurance and all payments will be applied to the account accordingly. In the event there is no coverage, insufficient coverage, or a deductible that exceeds $1500, we may offer a 'prompt pay discount' or ‘pre-payment discount’ consistent with what is offered to our private pay patients. You may elect to have us not bill your insurance company, even if we are in network, by selecting this option on the payment form.
Our office accepts insurance assignment under special conditions. After insurance coverage has been verified, we will submit claim forms directly to your insurance company and collect your patient co-payment and deductible, if applicable. However, please understand that this is a courtesy to you, and that you are fully responsible for any amount not paid by your insurance. The contract for health insurance is of course between you and your insurance company. Carefully review your “Explanation of Benefits” when you receive it in the mail. Call your insurance carrier directly to resolve any discrepancies on your claims to avoid out of pocket expenses. We will make every attempt to facilitate the processing of claim forms. Verification of benefits by our office does not guarantee that the insurance company will pay your claim. We will not enter into a dispute with your insurance company over your claim; however, we may help you provide information to assist you in filing a dispute. If you have an HMO, it is your responsibility to secure a referral and without it, you will be considered private pay.
In the event that your insurance company or attorney inadvertently sends payments to you for services we have performed, any checks should be endorsed and sent to Whole Family Chiropractors with the Explanation of Benefits that normally accompanies the check.
If you have sustained an injury on the job, and it is determined to have occurred during work related to your employment, we will refer you to a doctor that accepts Worker's Compensation cases.
If you have sustained a non-work-related personal injury it is our office policy regarding motor vehicle crashes (regardless of fault) that we will bill the appropriate PIP/MedPay policies, followed by 3rd party, and only as a last resort, at the end of treatment, will we decide whether to agree to bill health insurance. Regarding 3rd party claims, patients who are not legally represented will pay a minimum of $72 per regular office visit toward total fees and $105 toward any manual therapy fees. Please be aware that we do not discount our bill at the end of treatment for any reason.
By signing this office policy document, you agree to receive unencrypted email or text messages regarding missed appointments or other office reminders.
As part of our HIPAA policy, please understand that any information conveyed to the doctors will be shared between them and any information provided to the therapists is confidential within the referring provider group, but not between you and the therapist as they are working under the delegation of the doctors.
Returned checks will be assessed a $20.00 fee. An interest rate of 1.5% monthly may be applied to any unpaid balances. In signing below, I understand these policies and agree to pay for treatment accordingly, and also agree that I am responsible for any unpaid balances. I further understand that regarding personal injury med-legal cases, any monies due to Whole Family Chiropractors must be paid no later than 15 days following the date of settlement. Withholding payment or defaulting on a medical debt is considered a legal breech of this contract. I understand that Whole Family Chiropractors may report me to a credit-reporting agency or take legal action as necessary to be paid for services rendered. Whole Family Chiropractors reserves the right to charge reasonable collections for attorney’s fees and/or collection agency fees to all delinquent accounts. Should a credit remain on an account once a patient discontinues treatment for any reason, a full audit will occur, and any balance resolved within 45 days.
We offer hardship discounts for significant financial hardship on a case-by-case basis; we hope you will respect this offering and let us know if your financial outlook improves to extend this to another person. (Completed financial form required.)
If your doctor has suggested a treatment plan that you have agreed to that has a prepayment discount and you do not complete or comply with the plan, any monies paid in advance will be returned to you on a pro-rated basis.
We genuinely wish to provide you with the best service and treatment that we can. Please do not hesitate to let us know how we can better serve you. We genuinely care about each of our patients, care about the experience they have in our office and are honored and humbled each time someone entrusts us with their healthcare.
Our office will make every attempt to verify your policy benefits, however, this office and your insurance DOES NOT guarantee a quote of benefits for payment of services provided. Your insurance should pay within 35 days from the date in which claims are filed. If your insurance company does not pay in a timely manner, you may be asked to contact your insurance carrier. I, the undersigned patient/parent, grants and conveys to Whole Family Chiropractors LLC, a lien against the proceeds of the patient’s insurance settlement with all the following rights, power and authority.
I hereby assign the exclusive, irrevocable right to any cause of action that exists in my favor against any insurance company for the terms of the policy, including the exclusive, irrevocable right to receive payment for such services, make demand for payment, and prosecute and receive penalties, interest, court loss, or other legally compensable amounts owed by an insurance company in accordance with Article 21.55 of the Texas Insurance Code to cooperate, provide information as needed, and appear as needed to assist in the prosecution of such claims for benefits upon request. To any insurance company providing benefits or settlement of a claim, you are instructed to pay the total dollar amount of all sums which I owe on account to the above-named doctor and treating facility within 30 days following your receipt of such bills for services to the extent that such bills are payable under the terms of the policy. If my injuries are the result of negligence from a third party, then I instruct the Liability carrier to cut a separate check to pay in full all services rendered by this office.
I instruct checks to be made payable to: Whole Family Chiropractors LLC, and payment to be sent to 4818 Berkman Dr, Suite 100, Austin, TX 78723 This demand specifically conforms to Article 21.55 of the Texas Insurance Code, providing for attorney fees, 18% penalty, court cost, and interest from judgment, upon violation. In the event my insurance settlement proceeds are paid directly to my attorney, I hereby irrevocably instruct my attorney to withhold all such sums and amounts as are determined to be owed, due and payable on my account and remit payment of all such sums directly to the above-named doctor and/or treating facility upon receipt of my settlement award(s).
I hereby grant the above-named facility/physician the power to endorse my name upon any checks, drafts, or other negotiable instrument representing payment from any insurance company for treatment rendered by this office. I agree that any payment in excess of the charges for treatment rendered will be credited to my account or forwarded to my address.
I hereby authorize the above facility/physician to establish a PIP, Med Pay or UM claim on my behalf should I become involved in a motor vehicle injury. I also instruct my insurance carrier to provide upon request of the provider, any rejections in writing as they apply to my lack of PIP, Med Pay or UM/UIM coverage. If my carrier is unable to provide said rejections in a timely manner, I acknowledge that I am entitled to minimum levels of coverage, as per section 1952.152 of the Texas Insurance Code, and further instruct my carrier to pay up to available limits directly to the facility named above.
You are the decision maker for your health care. Part of our role is to provide you with information to assist you in making informed choices. This process is often referred to as “informed consent” and involves your understanding and agreement regarding the care we recommend, the benefits and risks associated with the care, alternatives, and the potential effect on your health if you choose not to receive the care.
We may conduct some diagnostic or examination procedures if indicated. Any examinations or tests conducted will be carefully performed but may be uncomfortable.
Chiropractic care centrally involves a chiropractic adjustment. There may be additional supportive procedures or recommendations. When providing an adjustment, we use our hands or an instrument to impact anatomical structures, such as vertebrae and muscles. Potential benefits of an adjustment include restoring normal joint motion, reducing swelling and inflammation in a joint, reducing pain in the joint, and improving neurological functioning and overall well-being.
It is important that you understand, as with all health care approaches, results are not guaranteed, and there is no promise to cure. As with all types of health care interventions, there are some risks to care, including, but not limited to: muscle spasms, aggravating and/or temporary increase in symptoms, lack of improvement of symptoms, burns and/or scarring from electrical stimulation and from hot or cold therapies, including but not limited to hot packs and ice, fractures (broken bones), disc injuries, strokes, dislocations, strains, and sprains. With respect to strokes, there is a rare but serious condition risk of a cervical Basilar Artery dissection that involves an abnormal change in the wall of an artery that may cause the development of a thrombus (clot) with the potential to lead to a stroke. This occurs in 3-4 of every 100,000 people whether they are receiving health care or not. Patients who experience this condition often, but not always, present to their medical doctor or chiropractor with neck pain and headache. Unfortunately, a percentage of these patients will experience a stroke. As chiropractic can involve manually and/or mechanically adjusting the cervical spine, it has been reported that chiropractic care may be a risk for developing this type of stroke. The association with stroke is exceedingly rare and it is estimated to be related to in one in one million to one in two million cervical adjustments.
It is also important that you understand there are treatment options available for your condition other than chiropractic procedures. Likely, you have tried many of these approaches already. These options may include, but are not limited to: self-administered care, over-the-counter pain relievers, physical measures and rest, medical care with prescription drugs, physical therapy, bracing, injections, and surgery. Lastly, you have the right to a second opinion and to secure other opinions about your circumstances and health care as you see fit.
I have read, or have had read to me, the above consent. I appreciate that it is not possible to consider every possible complication to care. I have also had an opportunity to ask questions about its content, and by signing below, I agree with the current or future recommendation to receive chiropractic care as is deemed appropriate for my circumstance. I intend this consent to cover the entire course of care from all providers in this office for my present condition and for any future condition(s) for which I seek chiropractic care from this office.
Though chiropractors read radiographs regularly, we at WFC routinely may wish to send X-rays to Austin Radiological Association (ARA) for a medical radiologist over-read because we are not adept at catching rare pathology and some fractures. You will be charged $20 for this service and will receive a copy of the professional report. If you wish to decline the over-read, you may do so, but recognize that it is our professional opinion and typical level of service that X-rays should also be read by a radiologist. We cannot be responsible for anything on an X-ray that we don't see and therefore, to ensure your safety, we feel it is important to offer this service.
☐ Check box only if you wish to decline this service.
I have read and agree to the office policies and the 4 pages of Whole Family Chiropractors and the 4 pages of this document.
In order for us to best estimate your costs of visit/s please provide your insurance information as soon as you can prior to your appointment. We take most major medical insurance and we try to match in-network benefits when your policy has out-of-network benefits. Without insurance or without time to verify your policy, the maximum cost of the first visit is $110 for exam, $115 for xrays (if ordered) and $62 for an adjustment (totaling $287). Payment plans are available, in some circumstances, when a card is on file.
Medicare covers only the adjustment, therefore the exam and xrays are not a covered service. A secondary will often cover these other charges but a supplement plan may not.
I grant permission for my healthcare provider and their representatives of Whole Family Chiropractors (WFC) to discuss my care, as it becomes relevant, using this disclosure form to share information about my healthcare or discuss financial information for payment on my account with family or friends.
Are there any specific people you would like the staff at WFC to disclose medical/appointment information to?
*WE WILL NOT TALK TO ANYONE THAT IS NOT ON THIS FORM, INCLUDINGYOUR SPOUSE, PARENT OR CHILDREN.*
Release my protected health information to the following person(s)/entity:
Name: name/entityPhone: phone Relationship: relationship to patient
Name:name/entity Phone: phone Relationship: relationship to patient
Name:name/entity Phone: phone Relationship: relationship to patient
The information you may release subject to this authorization is the following:
This consent will be considered valid until such time that I revoke it. I reserve the right to revoke it at any time.
I understand that to revoke this consent, I must provide written notice to WFC.