I HEREBY REQUEST AND CONSENT to the performance of Chiropractic procedures which may include but are not limited to various modes of physical medicine, therapies, joint manipulation, needling, and diagnostic tests on me by a licensed physician, residencies, chiropractic interns and/or other healthcare providers who are now or in the future employed by RESILIENT SPINE AND SPORTS HEALTH, LLC as deemed necessary. I understand I may refuse treatment(s) at any time.
I CERTIFY that all information provided to this office is true and correct, to the best of my knowledge, and will have the opportunity to discuss the nature of my case, including treatment, procedures, and other options. I understand that results are not guaranteed. I understand and am informed that in the applicable methods of treatment (chiropractic, dry needling, therapeutic exercise, etc.) there are some risks, including fracture, disc injuries, stroke, dislocation, sprains, pneumothorax, and infection. I do not expect the physician(s) or other provider(s) to be able to anticipate and explain all risks and complications, and I wish to rely upon the physician(s) or other providers judgement during the course of the treatment or procedure, given the facts known then to him/her, acting in my best interest.
I HAVE READ, or have had read to me, the above consent, and have been offered the amendment document “Informed Consent.” I have had the opportunity to ask questions about its content. By signing below, I agree to the above-named procedures. 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.
ASSIGNMENT AND INSTRUCTION FOR DIRECT PAYMENT TO THE FACILITY
I do hereby authorize RESILIENT HEALTH AND WELLNESS to furnish the insurance company, my attorney, or other interested party with full report of examination, diagnosis, treatment, prognosis, etc. regarding this injury or accident.
I hereby authorize and direct the insurance company, attorney, or other interested party to pay directly to RESILIENT HEALTH AND WELLNESS such as sums as may be due and owing for services rendered me and to withhold such sums for any settlement, judgement, or verdict as may be necessary to adequately protect RESILIENT HEALTH AND WELLNESS
I fully understand that I am directly and fully responsible to RESILIENT HEALTH AND WELLNESS for all bills submitted for services rendered, and that agreement is made solely for said facility’s settlement, judgement, or verdict by which I may eventually recover said fee. I further understand that I am fully responsible for all fees, court costs and all other fees associated with collection of this debt.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I acknowledge that I have been offered a copy of the RESILIENT HEALTH AND WELLNESS “Notice of Privacy Policies.” This notice describes how RSSH may use and disclose my protected health information, certain restrictions on the use and disclosure of that information and rights I may have regarding my protected health information.