Certain Waivers under HIPAA. (a) Patient acknowledges that neither Group nor Physician guarantees that communications with Physician using electronic mail ("e-mail"), facsimile, video chat, instant messaging, and cellular telephone are secure or confidential methods of communications. Accordingly, Patient expressly waives Group’s and Physician’s obligations under the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. § 1320d et seq.), as amended by the Health Information Technology for Economic and Clinical Health Act of 2009, and all rules and regulations promulgated thereunder (collectively, "HIPAA"), and other state and federal laws and regulations applicable to the use, maintenance, and disclosure of patient-related information, to guarantee confidentiality with respect to correspondence using such means of communication. Patient acknowledges that all such communications may become a part of Patient’s medical records maintained by Physician. (b) By providing Patient’s e-mail address to Physician, Patient authorizes Physician to communicate with Patient by e-mail regarding Patient’s "protected health information" ("PHI") (as defined under HIPAA) and Patient understands and agrees to the following: E-mail is not necessarily a secure medium for sending or receiving PHI and, accordingly, any third party may gain access to such PHI; Although Group and Physician will make all reasonable efforts to keep e-mail communications confidential and secure, neither Group nor Physician can assure or guarantee the absolute confidentiality of such e-mail communications.
The nature of the chiropractic adjustment:
The primary treatment used by doctors of chiropractic is spinal manipulative therapy. I will use that procedure to treat you. I may use my hands or a mechanical instrument upon your body in such a way as to move your joints. That may cause an audible "pop" or "click," much as you have experienced when you "crack" your knuckles. You may feel a sense of movement.
Analysis / Examination / Treatment:
As a part of the analysis, examination, and treatment, you are consenting to the following procedures:
-spinal manipulative therapy
-range of motion testing
-basic neurological testing
-muscle strength testing
-postural analysis testing
The risks inherent in chiropractic adjustment:
As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation and therapy. These complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, cervical myelopathy, costovertebral strains, separations and burns. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. Some patients will feel some stiffness and soreness following the first few days of treatment. The Doctor will make every reasonable effort during the examination to screen for contraindications to care. However, if you have a condition that would otherwise not come to the Doctor's attention it is your responsibility to inform the Doctor.
The probability of those risks occurring:
Fractures are rare occurrences and generally result from some underlying weakness of the bone which we check for during the taking of your history and during examination and X-ray. Stroke and/or arterial dissection caused by chiropractic manipulation of the neck has been the subject of ongoing medical research and debate. The most current research on the topic is inconclusive as to a specific incident of this complication occurring. If there is a causal relationship at all, it is extremely rare and remote. Unfortunately, there is no recognized screening procedure to identify patients with neck pain who are at risk of arterial stroke.
The availability and nature of other treatment options:
Other treatment options for your condition may include:
-Self-administered, over-the-counter analgesics and rest
-Medical care and prescription drugs such as anti-inflammatory, muscle
relaxants and painkillers
If you chose to use one of the above noted "other treatment" options, you should be aware that there are risks and benefits of such options and you may wish to discuss these with your primary medical physician.
The risks and dangers attendant to remaining untreated.
Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed.
Cancellations/No-shows: We understand that there are times in which circumstances arise where you may need to cancel your appointment. However, when you do not communicate this to us within a timely manner, you may be preventing another patient from receiving much needed care. Therefore, we have a cancellation policy in which patients must notify our office of a cancellation at least 24 hours prior to the scheduled appointment time. If you fail to provide sufficient notice, a cancellation fee of $25 with be charged to your account.
Late Appointments: We understand that delays occur sometimes. However, we must do everything we can to make sure the time of other patients and our doctors is valued and respected. Patients that exceed 15 minutes late will be rescheduled and charged a late fee of $25.
Fees are not covered by your insurance.
If you choose to keep your card information on file with our office, your card will be charged automatically at the time of your scheduled appointment time.
If you do not elect to keep your payment method on file, payment must be arranged prior to scheduling any future appointments.