For each of the conditions listed below, please place a check in past column if you have had the condition the past. If you presently have a condition listed below, place a check in the present column:
Information About Possible Risk of Chiropractic Treatment
Initials* You have the right, as a patient, to be informed about your condition and the recommended integrative and complementary procedure to be used so that you make an informed decision whether or not to undergo the procedure after knowing the risks and hazard involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give or withhold your consent to the procedure.Doctors of chiropractic, Medical Doctors and Physical Therapists using manual therapy treatment for patients with headaches and cervical spine (neck) complaints are required to explain that there have been rare cases of injury to a vertebral artery as a result of treatment. Such an injury has been known to cause a stroke, sometimes with serious neurological damage. The rare chance of this happening is estimated to be approximately from 1 to 400,000 treatments to 1 per 10 million treatments. Appropriate tests will be performed to help identify if you may be susceptible to this type of injury; you will be notified if that is the case. If you have any questions about this, please do not hesitate to speak with your practitioner.As with any health care procedure, complications may arise during treatment. These complications include soreness, muscle or ligament sprain/strain, dislocation, fractures, disc injuries or physiotherapy burns. These are extremely rare occurrences.
Consent for Treatment
Initials* I authorize the performance of diagnostic tests, procedures and treatment deemed necessary by personnel involved in my care.
Usual And Customary Rates
Initials* Whole Body Balance is committed to providing the best care for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates.
Thank you for choosing Whole Body balance, Inc. as your health care provider. We are committed to the success of your care. Please understand that payment is considered part of your care. The following is a statement of our Financial Policy, which we require you to read and sign prior to any care.
WHOLE BODY BALANCE ACCEPTS CASH, CHECK, VISA, MASTER CARD, and DISCOVER.
Whole Body balance is in-network with several private insurance plans, including Aetna, United Healthcare, and Cigna. We are happy to check your insurance benefits, as a courtesy, but please note that it is ultimately your responsibility to understand what services are covered under your insurance policy.If you have insurance benefits, we are happy to process your insurance claims. To prevent any misunderstandings about your insurance coverage and our billing / collections procedure, we would like to inform our patients that we cannot render services under the ASSUMPTION that we will be reimbursed by your insurance company. Please understand that you will be fully responsible for all professional services that your insurance company does not pay.It is our policy to:
Chiropractic New Patient Information
We normally provide information about your health to you in person at the time you receive chiropractic care from us. We may also mail information to you regarding your health care or about the status of your account. If you would like to receive this information at an address other than your home or, if you would like this information in a different form please advise us in writing as to your preferences.
You have the right to inspect and/or copy your health information for seven years from the date that the record was created or as long as the information remains in our files. In addition you have the right to request an amendment to your health information. Requests to inspect, copy or amend your health related information should be provided to us in writing.
We are required by state and federal law to maintain the privacy of your patient file and the health protected health information therein. We are also required to provide you with this notice of our privacy practices with respect to your health information.
We are further required by law to abide by the terms of this notice while it is in effect. We reserve the right to alter or amend the terms of this privacy notice. If changes are made to our privacy notice we will notify you in writing as soon as possible following the changes. Any change in our privacy notice will apply for all of your health information in our files.
Information that we use or disclose based on this privacy notice may be subject to re-disclosure by the person to whom we provide the information and may no longer be protected by the federal privacy rules.
If you have a complaint regarding our privacy notice, our privacy practices or any aspect of our privacy activities you should direct your complaint to your Whole Body Balance provider
If you would like further information about our privacy policies and practices please contact Matt Miller or Garret Rock.
This notice is effective as of (today’s date) Date*. This notice, and any alterations or amendments made hereto will expire seven years after the date upon which the record was created. My signature acknowledges that I have read and understand this notice.
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW CHIROPRACTIC AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
In the course of your care as a patient at Whole Body Balance, we may use or disclose personal and health related information about you in the following ways:
If you are not at home to receive an appointment reminder, a message may be left on your answering machine. Further, you have the right to inspect or obtain a copy of the information we will use for these purposes. You also have the right to refuse to provide authorization for this office to contact you regarding these matters. If you do not provide us with this authorization it will not affect the care provided to you or the reimbursement avenues associated with your care.Under Federal Law, we are also permitted or required to use or disclose your health information without your consent or authorization in these following circumstances:
Any use or disclosure of your protected health information, other as outlined above, will only be made upon your written authorization.
Authorization to Treat a Minor (under the age of 18)
I hereby request and authorize my doctor at this clinic to perform diagnostic tests and render chiropractic adjustment and other treatment to my minor son/daughter. This authorization also extends to include radiographic examination at the doctor’s discretion. As of this date, I have legal right to select and authorize health care services for the minor child named above. Under the terms and conditions of my divorce (if applicable), separation or other authorization, the consent of a spouse/former spouse or other parent is not required. If my authority to so select and authorize this care should be revoked or modified in any way, I will immediately notify Whole Body Balance.