1. CONSENT TO ROUTINE CLINIC SERVICES: I consent to the services being rendered during this visit on an outpatient basis by the licensed Providers at Balance Wellspace Integrative Medicine, who now or in the future treat me while employed by, working or associated with or serving as back up for the Organization named above. I understand that I am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to chiropractic manipulative therapy, including but not limited to fractures, disc injuries, strokes, dislocations and sprains. I do not expect the Provider to be able to anticipate and explain all risks and complications, and I wish to rely on the Provider to exercise judgment during the course of the procedure which the Provider feels at the time, based upon the facts then known, is in my best interests. I understand that no guarantee has been made to me as to the result or cures that may be obtained from examination or treatment in this clinic. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.
2. AUTHORIZATION FOR DIRECT PAYMENT OF INSURANCE BENEFITS TO THE HEALTHCARE PROVIDER AND CLINCS: I, or my representative, authorize direct payment to the Provider(s) and/or clinic rendering any services during this visit of any insurance benefits otherwise payable to me.
3. MEDICARE CERTIFICATION AND PAYMENT REQUEST: I certify that the information given by me in applying for payment under Title XVIII and / or Title XI of the Social security Act is correct. I authorize any holder of medical or other information about me to release to my Physician, my Caregiver, to CMS or its agents, to the Social Security Administration or its intermediary carriers, any information needed for this or related Medicare or Medicaid claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for provider services to the provider(s) or organization furnishing the services or authorize them to submit a claim to Medicare or Medicaid on my behalf.
4. AUTHORIZATION TO RELEASE INFORMATION: In obtaining payment for services, I authorize my healthcare provider(s) to furnish information from my medical records to any company that may be responsible for payment of all or part of my visit and provider charges, including my insurance companies and their representatives, and my information to this provider for continuing care.
5. PROTECTED DIAGNOSIS: If my medical record contains information about drug or alcohol diagnosis or treatment of HIV testing, I specifically authorize the release of this information for billing purposes ONLY. I understand that the specific time period during which release of this information may occur will be 180 days after I sign this consent form. It may be revoked at any time except to the extent that action has been taken in reliance on the consent.
6.PATIENT HEALTH INFORMATION: I understand and agree to allow this medical office to use their Patient Health Information for the purpose of treatment, payment, healthcare operations, and coordination of care. We want you to know how your Patient Health Information is going to be used in this office and your rights concerning those records. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPPA NOTICE that is available to you at the front desk before signing this consent. If there is anyone you do not want to receive your medical records, please inform our office. By signing this document, I or my representative, acknowledge that I have received the Balance Wellspace Notice of Privacy Practices for protected health information.
7. I give Balance Wellspace, and other health practitioners and employees the absolute right and unrestricted permission to take/use my name, testimonial, biographical data, and protected health information voluntarily disclosed to me to publish, reproduce, edit, exhibit, project, display, and/or copyrighted images or pictures of me, whether still, single,multiple, or moving, or which I may include in
whole or part, in color or otherwise, through any form of media taken at the practice of Balance Wellspace for advertisement,recruitment,marketing, publicity, or any other lawful purpose. I waive my right to royalties or other compensation arising from or related to the use of this testimonial. I certify that I am at least 18 years of age (or if under 18 years of age that I am joined here in by legal parent or
legal guardian) and that this release is signed voluntarily under no duress, and with expectation of compensation in any form now or in the future.
Further:
I expressly acknowledge that this authorization is voluntary. The authorization is valid until it is revoked by me in writing. I understand that this authorization may be revoked by me at any time, provided I notify Balance Wellspace in writing. I understand that the protected health information I voluntarily redisclosed will be re disclosed by Health Advantage as disclosed in this authorization and that information will no longer be protected by HIPAA privacy rules.
I, OR MY REPRESENTATIVE, HAVE READ, FULLY UNDERSTAND AND AGREE TO THE ABOVE STATEMENTS.