Whole Body Balance

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.

Financial Policy

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:

• Collect all co-pays at the time services are rendered.
• Collect full payment for cash patients the day services are rendered. If payment is not collected on the day of service, the time of service discount will no longer apply and you will be billed the full standard fee.
• A $30 late fee cancellation charge will occur if a patient cancels within 24-hours of their visit.
• Patient will be responsible for a full price charge if they do not show nor call to cancel their appointment prior to 1-hour of their visit. 

Signature*   

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.