Pediatric Chiropractic Intake Form

We are committed to providing the best care possible for you and your family to assist you with your healthcare needs.

Currently we are not an on-call clinic. We do not have a provider on call on weekends or after hours. If you need assistance, please call us at the office during normal business hours 9-5 and we will be happy to assist you. If leaving a message we will return your call in 48hrs.

Please check with your insurance company prior to making an appointment to verify if we are in network with your insurance company. You will be responsible for any amount not covered by insurance.

I acknowledge and understand that, in presenting myself for treatment and medical care under Ideal Health & Wellness, I authorize and consent to the administration and performance of all tests and treatments to which may be ordered by the physician and carried out by members of the staff. Minors must be accompanied by a parent/legal guardian for medical care.

Privacy Notice We will maintain the privacy of your health information. Test results will only be given to the patient or the parent/legal guardian, unless written authorization is obtained from the patient. Medical information is released to third-party payers, other health practitioners, radiology, lab, and as needed to facilitate appropriate medical treatment with each patient. We follow the guidelines of the Health Insurance Portability Act (HIPPA). You may request to see our full Notice of Privacy Practices at any time and will be given a copy and asked to re-sign yearly. 

Please sign below if you agree with the following statement: As the parent/legal guardian of the indicated patient (please indicate patient name below), I have been informed of the risks, benefits, and alternatives to care, I am authorizing my child to receive a chiropractic evaluation, including history, examination and x-rays if warranted, by an Ideal Health and Wellness Provider.  Any findings will be communicated before consenting to commencement of treatment, if appropriate (please check the box below).

Thank you for choosing our practice for your health care needs. We offer patients a truly integrative approach to health with the blend of traditional medicine, functional medicine, naturopathic medicine, chiropractic, acupuncture, and massage to provide the best healthcare possible.

Insurance: As a courtesy to our patients, we are contracted with Blue Cross Blue Shield PPO, United Healthcare, and Quad City Community Healthcare. For those patients, with one of the above insurances, we will submit claims for you. All outstanding balances after insurance settlement will be charged to the given credit card. Please see the Financial Policy for further details. As a patient, it is your responsibility to know what is/is not covered by your insurance company.

Other Insurance Companies

We see many patients with other insurances as an out-of-network provider. In these cases, payment in full is required prior to any further care in our clinic. As needed, we will provide a superbill to you so you can send it to your insurance company for reimbursement purposes.

It is your responsibility to know your insurance benefit coverage. We will file your claim forms to assist you in every way we can for reimbursement from plans that we are an in-network provider. We must make it clear that insurance contracts are between you, the patient, and your insurance company. You are responsible for any amount not paid by your insurance company/or paid directly to you from the insurance company (for example, some groups send our payment to you for you to send to us).

CONTINUED

By accepting your insurance on assignment, we are extending credit to you. This courtesy may be withdrawn if circumstances below warrant. It is imperative that you understand these conditions and agree to them: Your insurance should pay within 30 days of your office visit. If your insurance has not paid within 60 days, then you will be responsible to pay the balance due. You will be reimbursed by our office when your insurance company pays the outstanding balance.

1. We will continue to bill your insurance as long as you are receiving active care in our office.

2. We require a valid credit card be kept on file with your account. This card will be charged in the event you are required to pay a coinsurance /deductible /additional copay per your policy.

3. Deductibles must be satisfied prior to assignment being enacted.

4. Copayment will be collected at time of service.

5. You are required to sign the informed consent, medical release forms, as well as any other assignment documents required by your insurance company.

6. Our office does not guarantee that your insurance company will pay. If, for any reason, your insurance claim is denied, you are responsible for the full amount of your balance. Any past due accounts are subject to a 3% monthly fee after 90 days. If an account is six months past due, it will be sent to collections.

7. Our office will not enter into a dispute with your insurance company over any claim. This is ultimately your responsibility and obligation.

8. Returned checks are subject to a $50.00 fee.

If you understand and agree with all of the above policies, please sign your name below, and we will accept your insurance assignment as stated above.

Appointments: We require separate visits for each problem due to time constraints. If your medical visit is greater than the allotted time, and/or there are complicated medical problems, we often add a prolonged visit code and/or an additional medical code. This may or may not be covered by your insurance. We realize your time is valuable, and you may not want to schedule another visit due to time constraints. However, we need to appropriately charge for the doctor's time.

Coding of Visits: In general, we will not re-code visits after the medical visit has been submitted to your insurance company.

Late for an appointment: If you arrive to your appointment more than 5 min late for chiro, 5 min late for acute appointments, or 10 for any other appointments including functional, you will have to reschedule for another day.

Canceling an Appointment: Should you need to cancel an appointment, please give our office 24-hour notice (48 hours for Functional Medicine). Any appointment cancelled with less than the appropriate notice is subject to a cancellation fee, which will be billed to the card on file. Failure to cancel/no show (you do not come in for your appointment) will result in the cancellation fee. If you do not have a valid card on file, you will be required to pay the cancellation fee prior to any future scheduling at IHW. Three no show appointments and you will be discharged from the practice.

The No Show/Late Cancellation fees are as follows:
Chiro: $50
Mental Health: $80
Naturo/Functional Medicine: $100

This is in place for all patients for all parts of the practice. You have one grace no
show or Late Cancelation with one provider in our clinic. If you no show or are late
for further appointments with same or any other provider past your first, you will
be charged the no show fee/late cancelation fee.

Telephone Calls: Our staff may handle brief questions, but in-depth questions will require an appointment with the Provider or a billable phone consult.

Use of Dictation Assistant (AI Dictation)- We are committed to providing the best possible care and are continually looking for ways to enhance our services. Currently, some of our providers are utilizing AI tools to assist them during patient appointments by generating clinical notes based on our conversations allowing us to focus more on you and less on computer documentation. Their AI tools do not interact with you directly but make a written summary or note based on your conversation which is then reviewed and approved by your provider. Your privacy is our utmost priority, and the AI tools are adherent to HIPAA compliance guidelines to ensure your data is secured and protected. Only the healthcare professionals involved in your care can have access to these notes. Your participation is voluntary, and you can decline the use of AI tools at any time.  

Labs: We use a third-party laboratory for our lab services. You are responsible for ensuring that HealthLabs through Northwestern Medicine out of Winfield, IL is in-network with your insurance. We do not handle the billing for HealthLabs. Should you have an issue with a lab bill, you will have to reach out to HealthLabs directly.

Acknowledgement: By signing below, you acknowledge that you have read, understood, and will abide by the policies and procedures of Ideal Health & Wellness.

You will be given a full Notice of Privacy Practices to sign at first appointment and every year following.

I designate the following family members and/or friends as eligible to share my protected health information. Information will not be shared with Persons NOT Listed on this form.

I understand that permission to release my health information to the family members and/or friends listed on this form is for a period of one (1) year, and that I may renew the permission at the end of one (1) year. I also understand that I may revoke permission to share my health information with a family member or friend, at any time, by submitting a request, in writing, to Ideal Health & Wellness.

As you know, if you have ever checked into a hotel or rented a car, the first thing you are asked for is a credit card. The card is then imprinted and later used to pay your bills. This is an advantage for both you and the hotel/rental company since it makes checkout easier, faster, and more efficient.

We have implemented a similar policy. You will be asked for a credit card number at your first appointment and when it needs to be updated. Your credit information will be held securely. After your insurances have paid their portion and notified us regarding the amount you owe, any remaining balance will be charged to your credit card and a receipt will be mailed to you. This applies to balances for office visits, labs, and other services.

This will be an advantage to you since you will no longer have to write and mail checks to us. It will be an advantage to us as well, since it will greatly decrease the number of statements that must be generated and sent. The combination will benefit everyone in helping to keep the cost of health care down. This in no way will compromise your ability to dispute a charge or question your insurance company's determination of payment. Copays are still due at the time of the visit. If you have any questions about this payment method, do not hesitate to ask.

The fee for a returned check is $50.00. This fee will automatically be charged to your account when your check is returned from the bank. If all payments are not received by this office within 90 days, you will be unable to schedule further appointments until all outstanding monies are received. Any account balance past 90 days will be assessed 10% fee per month until account is paid in full. After six months, your account will be sent to collections.

Please note: If your insurance sends checks to you instead of our practice, you are responsible for the balance. Please sign the insurance check over to Ideal Health & Wellness. Bring the check and your EOB (Explanation of Benefits), and we will credit your account accordingly. Please note- failure to do so, constitutes insurance fraud and will be reported.