PERSONAL HEALTH HISTORY

Check all conditions that apply to you:

NEUROLOGICAL AND VASCULAR PATIENT QUESTIONAIRE

1. Our clinic has established a single fee schedule that applies to all patients for each service provided.

2. You may be entitled to a network or contractual discount under the following circumstances:

a. We are a participating provider in your health plan.

b. You are covered by a State or Federal program with a mandated fee schedule.

c. You are a member of ChiroHealthUSA, or any other Discount Medical Plan Organization we may join. Patients who are uninsured, or underinsured (limited benefits for chiropractic care), may join ChiroHealthUSA in our office and will be entitled to network discounts similar to our insured patients. Membership is $49.00 a year and covers you and your dependents. Ask our staff for more information.

d. Patients who meet state and or federal poverty guidelines or other special circumstances outlined in our “Hardship Policy” may be offered a discount for a period of time as determined by the clinic. Verification will be required.

3. As part of our compliance plan, as of July 18, 2011 our office will be unable to extend any type of discounts other than those listed above.

Appointments 
In order to better serve our patients, we ask that you cancel your appointment with at least 24 hours notice. Your appointment time is reserved for you. If you fail to notify our office, it leaves a time slot open that could have been used to help someone else. Balance Wellspace will charge $50 for the missed visit if 24 hour notice is not provided. This amount is not covered by any insurance plan and will be the patient’s responsibility. Thank you for your consideration and helping us help others.   
                                                                                        
Patient Payment Policy 
In the event you do not have insurance coverage or are under-insured, we are here to serve everyone in this community. Therefore, part of this service means making sure that money is never a barrier to good healthcare. We offer affordable cash payment plans and are always willing to work out a program that is appropriate to your situation. That being said, payment for all services, including copays, coinsurance and deductibles, are expected at the time of service unless you are on a payment plan.  If you have a cash balance with our office greater than 45 days, we reserve the right to charge a finance charge of 1.5% per month. In the event your account is not paid and necessitates a collection effort, you will be responsible for any and all fees associated with the collection of your account. There will be a $35.00 fee for all checks and auto debit transactions returned for insufficient funds.   

 
Out of Pocket Estimate Policy 
We verify benefits based on what is presented in our office. If you are a candidate for care in our office and agree to the recommended treatment plan, we will provide you with an estimate of your out of pocket at your next visit. The numbers will be an estimate based on the fee schedule of the appropriate insurance contract or through a network you may choose to join called ChiroHealth USA (CHUSA) for our under-insured or out of network patients. This network allows us to legally discount our services to a level matching many of our insurance contracts – ultimately allowing us to provide our care at an affordable rate. Unfortunately, this estimate does not take into account necessary changes to accomplish your goals.  Insurance benefits can change while on a treatment plan in our office based on other medical care received outside of our office – which can affect benefits and ultimately out of pocket expenses. In some instances, this can mean more than what we project and in other instances it could mean less than we project. It is important that you communicate any insurance changes to us as soon as possible so we can remain transparent with your estimated out of pocket expenses.                                                                                                                                     
             
Our Policy on Health Insurance 
Today most insurance policies do cover chiropractic care. We will be happy to file your primary insurance claim for you and do everything we can to insure you receive proper reimbursement. However, we cannot take responsibility for what your health insurance will or will not cover. If you do not maintain that policy, you will be given the option to join a medical discount network called ChiroHealth USA (CHUSA) for an additional fee. If you choose not to join CHUSA, the regular fee schedule will apply. In the event your account is not paid and necessitates a collection effort, you will be responsible for any and all fees associated with the collection of your account.  In order to facilitate the correct and rapid processing of your insurance claim, we suggest that you contact your insurance company and determine what chiropractic coverage you have on your policy.  

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 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.

I, OR MY REPRESENTATIVE, HAVE READ, FULLY UNDERSTAND AND AGREE TO THE ABOVE STATEMENTS.