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INFORMED CONSENT TO TREATMENT
To the patient or their parent, legal guardian: Please read this entire form prior to signing it. It is important that you understand the information contained in this form. Please ask any questions prior to signing this form if you are unclear about anything in this form.
• A physical examination will be performed to obtain a baseline level of functioning as well to partially determine an appropriate course of treatment and associated recommendations. The physical examination may include posture checks, X-rays, diagnostic ultrasound, range of motion testing, muscle strength testing, various neurological and orthopedic testing, and other testing. Radiology is the use of x-rays on the human body and is used to gain an inside perspective of the human body that cannot be obtained from a physical examination. Additionally, there may be referrals to other doctors as necessary.
• The vast majority of our patients tend to achieve good to excellent improvement in their physical conditions with the use of physical medicine and in conjunction with other modalities. Improvement can be measured in many different ways, including reduction in pain, increased range of motion, less stiffness, increased athletic performance, and other ways. It must be remembered that different people get different results; different people have pre-existing conditions, and are of different ages and occupations (with different types of physical stress). Your situation is unique, and no guarantees are given.
• I understand and am informed that, as in the practice of medicine and all healthcare, the practice of physical medicine, massage therapy, acupuncture carries some risk to treatment; some including, but limited to: fracture, disc injuries, strokes and sprains.
• I understand acupuncture is a safe therapy, but there are some possible side effects. I may experience bruising, tingling, discomfort and pain close to the sites of needling or cupping that may last for several days. Nausea, lightheartedness or dizziness occasionally occur following treatment. I understand it is best to eat a snack or light meal 1-2 hours prior to treatment, to avoid these symptoms.
• I understand if I am receiving massage therapy, physical medicine, or acupuncture, I do not expect the physicians to be able to anticipate and explain all risks and complications.
Further, I wish to rely on the physician(s) to exercise judgment during the course of the procedure with what the physician feels are in my best interests at the time, based upon the facts then known.
Because clarity about financial matters is essential for you to receive optimum benefit from your care, we have outlined our financial policies and agreements below. Please read carefully and sign or initial where indicated. I understand and agree to the following:
A. I am solely responsible for the expenses of my care and/or the care of my dependents. While I may assign payment benefits to North Portland Wellness Group (NPWG), any uncovered services, deductibles, and co-payments are my financial obligation, to the extent allowed by the terms of the NPWG’s provider contracts with insurance plans.
B. A no-show is defined as a patient who never arrived at their scheduled appointment. A fee of $50 will be applied to patients file if there is more than two “no call, no shows”. We can always get you on the schedule for a different day if something comes up. Please give us a call and let us know within 24 hours if you can’t make it to avoid this fee. C. Assignment, group accident and health insurance Any amount authorized to be paid directly to North Portland Wellness Group will be credited to your account upon receipt.
Insurance non-covered service disclosure and agreement
1. Potential reasons for non-covered status include: The service is or may be deemed (a) investigational or experimental under the carrier’s internal guidelines; (b) not medically necessary under the carrier’s internal care or cost management guidelines; (c) not actually covered under the plan to which you are subscribed; (d) not provided in accordance with the Provider’s Agreement with the carrier or other requirements of the carrier’s or managed care entity’s internal guidelines.
2. The carrier authorizes the provider to charge the patient for the above services so long as this disclosure is made and signed by the patient prior to the services being provided.
3. I acknowledge that the Non-Covered status of the proposed service(s) has been explained and that a certain portion of my care may not be covered by or has not been authorized by my insurance plan. If any portion of the care provided is not, or may not be covered by insurance, then I shall be responsible for payment and shall make the necessary financial arrangement with the healthcare provider to pay for these services.
Choice of payment optionsWe are happy to provide the following payment options. If you are choosing to use your insurance you will need to pick a second option for any services not covered by your insurance. Generally, insurance will only a portion of the recommended care plan.
ACKNOWLEDGMENT AND CONSENT
I understand that North Portland Wellness Group will use and disclose health information about me. I understand that my health information may include information both created and received by North Portland Wellness Group may be in the form of electronic or written records or spoken words, and may include information about my health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, and similar types of health-related information.
I understand and agree that North Portland Wellness Group may use and disclose my health information in order to:
• Make decisions regarding my care and treatment
• Refer to, consult with, coordinate among, and manage along with other health care providers for my care and treatment
• Determine my eligibility for health plan or insurance coverage, submit bills, claims and other related information to insurance companies or others who may be responsible to pay for some or all of my health care
• Perform various office, administrative and business functions that support my physician’s efforts to provide me with, arrange and be reimbursed for quality, cost effective health care.
• Send and receive prescription information electronically and verbally from pharmacies
I also understand that I have the right to receive and review a written description of how North Portland Wellness Group will handle health information about me. This written description is known as a Notice of Privacy Practices and describes the uses and disclosures of health information, the information practices followed by the employees, staff and other office personnel of North Portland Wellness Group and my rights regarding my health information.
I understand that the Notice of Privacy Practices may be revised from time to time, and that I am entitled to receive a copy of any revised Notice of Privacy Practices.
I also understand that a copy or a summary of the most current version of Portland Wellness Care’s Notice of Privacy Practices is posted in the waiting room/reception area.
I understand that I have the right to ask that some or all of my health information not be used or disclosed in the manner described in the Notice of Privacy Practices
I understand that North Portland Wellness Group is not required by law to agree to such requests. By signing below,
I agree that I have reviewed and understood the information above and that I have received a copy of the Notice of Privacy Practice