ASSIGNMENT AND RELEASE
I certify that I, and/or my dependent(s), have insurance coverage with Name of Insurance Company(ies) and assign directly to Dr.Name all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
The above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
IN CASE OF EMERGENCY, CONTACT
Name and address of doctor(s) or other healthcare practitioner(s) who have treated you for your condition:
6. MASSAGE HISTORY
7. HEALTH HISTORY
To the best of my knowledge, the above information is complete and correct. I understand that reporting incomplete or inaccurate information can be dangerous to my health. I understand that I am solely responsible for any errors or omissions that I may have made in the completion of this form. I understand that it is my responsibility to inform my health care provider if I ever have a change in health.
I understand that massage therapy services are for the primary purpose of short-term relaxation and the relief of muscular tension. I understand that massage therapy services are in no way a substitute for examination, diagnosis or treatment by a physician. I understand that individuals providing massage therapy services are not qualified to diagnose, prescribe or treat any physical or mental illness and are not qualified to perform spinal or skeletal adjustments. I acknowledge that any information I receive from individuals performing massage therapy services is educational in nature and is to be used at my own discretion.
Functional Pain IndexPlease check the appropriate box to let us know how you feel TODAY.
Thank you for choosing Atlas Chiropractic Health Center. We appreciate the opportunity to serve you and pledge to provide you with the very best in health care. The following contains information regarding our insurance benefits and financial responsibility policies. It is important that you read and understand this information prior to and during the duration of your treatment with us. Please initial each section.
Commercial Insurance Carriers
1. As a courtesy, we will verify your benefit eligibility, however, since your insurance coverage is a contract between you and your insurance company, it is important that you understand the terms set forth by them regarding your benefits. It is your responsibility to contact your carrier prior to treatment if you have any questions or concerns regarding your coverage.
2. You are responsible for deductibles, co-payments, co-insurance payments or any other patient responsibility determined by your insurance carrier which is not otherwise covered. You are also responsible for knowing and tracking your total allowed visits per coverage term as well as if a prior authorization is required.
3. You are responsible for knowing the terms of your insurance policy, including, but not limited to chiropractic, physical and occupational therapy coverage. You will be responsible for any and all charges in full for the following scenarios:
a. Your health plan requires a prior authorization or referral from a physician before receiving treatment at Atlas Chiropractic Health Center and has not been provided by you.
b. You receive services in excess of:
i. Your referral or authorization
ii. Your allowed visits per coverage term
c. Your health plan determines that the services you received at Atlas Chiropractic Health Center are not medically necessary and are therefore not covered by your plan.
d. Your health plan coverage has expired, and you have not provided updated coverage information.
4. You are required to provide us with all required information to bill your plan prior to your first appointment. If we are unable to verify your eligibility or benefits by the time of service, you will be considered a self-pay patient. Self-pay visits are expected to be paid in full at the time of service. Once verified information is provided, we will submit your claim and refund you once we have been paid by your carrier. You must notify us as soon as possible regarding any changes to your insurance coverage. Failing to do so could result in unpaid claims, and you will be responsible for the total balance of the unpaid claim. Atlas Chiropractic Health Center does not accept responsibility for incorrect information provided by you or your insurance carrier regarding your insurance benefits or other plan information. Any information we communicate to you has come directly from your carrier. Discrepancies should be addressed directly with them.
5. Billing statements are emailed monthly and can be expected to be received approximately 20-30 days after your insurance has processed a submitted claim. Please add firstname.lastname@example.org to your list of acceptable contacts. We are not responsible if our emails are sent to your spam or junk boxes. You must notify us of any errors or objections to your billing statement within 30 days of the statement date, otherwise the information will be considered accurate and any fees and expenses for services provided will be your responsibility.
6. Payment of your account balance is due within 30 days of the statement billing date. Payments can be made online, in person, or via mail. You can conveniently pay by visiting our website or making payment by PayPal or Square. Check, cash and all major debit and credit cards are also accepted in office. It is your responsibility to notify us of any address changes. Not receiving a bill due to inaccurate information on file is not an excuse for nonpayment.
7. All self-pay services and co-pays are required to be paid in full at the time of service. All self-pay patients without insurance in accordance with the law will be given a good faith estimate.
Auto Accidents: PIP Claims/Third-Party Liability Injuries
1. As a courtesy, we will bill your PIP carrier for services. It is your responsibility to ensure that your claim is open and accepting claims for payment of services you will be receiving prior to your initial visit. Legally we do not have access to information regarding the remaining available PIP carrier funds associated with your claim. It is your responsibility to know when your claim’s funds may become exhausted. It is common for us to only become aware that funds have been exhausted after several additional visits have occurred.
2. You are responsible for providing us all required information to bill your claim directly. This includes but is not limited to:
a. Name of your carrier
b. Claim number
c. Billing address
d. Name and contact information for your claim manager
e. Date of birth, date of injury, and state where accident took place
f. Attorney Name and Contact Information (if applicable)
g. Commercial medical insurance plan information as back up billing source if needed
3. In the event that your PIP carrier funds become exhausted during your course of treatment, we will make an attempt to bill your primary commercial medical insurance plan. If the claim is denied by both parties, you will be billed and required to pay all amounts within 30 days of the statement billing date. We will only accept a delay in payment resulting from a settlement with a 3rd party dispute and/or litigation when a letter of protection from an attorney as a guarantee of payment has been signed by both patient and attorney and is on file.
Work Injuries: Workers’ Compensation/L&I Claims
1. If treatment is part of a workers’ compensation/L&I claim it is your responsibility to ensure that your claim is opened and accepting claims for payment of services you will be receiving prior to your initial visit. It is also your responsibility to know how many visits you are allowed and to notify us if you are receiving subsequent care at another location that is also being billed under the same claim. This may affect how may visits will be paid to Atlas Chiropractic Health Center and we are not responsible for tracking visits that take place outside of our location. We will do our best to obtain additional authorized visits in a timely manner, however any unauthorized visits are ultimately your responsibility. It is important that you are regularly communicating with your claim manager so that you are aware of the coverage associated with your claim.
2. You are responsible for providing us all required information to bill your claim directly. This includes but is not limited to the following:
a. Claim Number
b. Carrier name and mailing address if the claim is being paid by a carrier other than the state of Washington
c. Date of birth and date of injury
e. Primary Care Physician in charge of your case (if applicable)
f. Commercial medical insurance plan information as back up billing source if needed
3. In the event that your claim is denied we will make an attempt to bill your primary commercial medical insurance plan. If the claim is denied by both parties, you will be billed and required to pay all amounts within 30 days of the statement billing date.
Past Due Balances
Atlas Chiropractic Health Center will work with you to ensure a timely payment of your outstanding balance. Outstanding balances beyond 6 months will be sent to collections unless a payment plan has been discussed and signed. In the event that it becomes necessary to begin collection proceedings on a delinquent account, you understand that Atlas Chiropractic Health Center has the right to disclose to an outside collection agency all pertinent personal information required to collect payment for services rendered. You are responsible for all costs associated with any collection efforts. You also understand that information may be reported to a credit reporting agency which may have a negative effect on your credit history.
Cancellation Fee Policy
A credit card must be on file for all appointments at Atlas Chiropractic Health Center.
a.Cancellations made more than 24 hours in advance incur no fees.
b. For chiropractic new patient appointments: cancellations made within 24 hours or no-call, no-shows will be charged $100.
c. For routine chiropractic appointments: no-call, no-shows will be charged $25.00.
d. For massage appointments: Cancellations within 24 hours will be charged $50.00; cancellations within 12 hours or no-shows will be charged $100.00.
e. Cancellation fees will be automatically charged to the credit card on file, and clients will be given 48 hours to provide an alternative payment method if the card is declined. Clients are responsible for any applicable fees and agree to this policy upon scheduling. All cancellation and no-call, no-show fees cannot be billed to any insurance company. Note that this policy is subject to change without notice.
Please sign below acknowledging that you have read and understand the insurance benefits and financial policies stated above.
Atlas Chiropractic Massage Appointment Policy
In order to provide you and our other patients with optimal care, we request that you follow our guidelines regarding massage appointments.
In order to avoid a $40.00 fee (that cannot be billed to any insurance company), please provide 24+ hours when cancelling or rescheduling massage appointments.
These policies were adopted to ensure the best overall experience for you and our therapists. Thank you for your consideration of our policies and for the opportunity to be your chiropractic office of choice.
I have read and understand the financial policy of Atlas Chiropractic Health Center. I also understand that if I have insurance, or a valid auto or workman’s compensation claim, my carrier may pay for some to most of the charges listed above, but no benefits are guaranteed. I understand that I am ultimately financially responsible for all services not paid by insurance or other third party. Should there be a balance due at the end of my treatment plan, I will receive an invoice for the amount and pay it promptly or contact the office to make payment arrangements.
Summary: By law, we are required to provide you with our NPP - Notice of Privacy Practices.
This notice describes how medical/protected health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
As a patient, you have the following rights:
We want to assure you that your medical/PHI is secure with us. This notice contains information about how we will insure that your information remains private. If you have any questions about this notice Effective October 15, 2018, please contact the HIPAA Compliance Officer at 206-324-2225 or email@example.com.
Acknowledgment: I hereby acknowledge that I have received a copy of this practice's NPP, I understand that if I have questions I may contact the HIPAA Compliance Officer.