Griffin Family Wellness

Health Insurance  (Primary)

Health Insurance  (Secondary)

Griffin Family Wellness Consent To Services

 

Patient Consent for Evaluation & Treatment / Authorization to Treat a Minor

By Signing this form, you are consenting to an examination by Doctors from Griffin Family Wellness.  Doctors from Griffin Family Wellness employ standard Chiropractic and/or physical therapy examination methods which include, but are not limited to, the following:

1. Observation:  General assessment/appraisal in all positions.
2. Inspection:  Visual examination of your injuries which include general body viewing inja standing, seated, and/or lying covering front, back, and/or sides.  All symptomatic (painful) body parts may be viewed.
3. Auscultation:  using a stethoscope to listen to blood pressure and other body sounds.
4. Palpation:  the procedure where the doctor places his/her hands on you for examination purposes.  The doctor will feel for tenderness, heat, swelling, nodularity, laxity of tissues, integrity, and abnormality.
5. Percussion:  using a rubber hammer and/or fingers while tapping bones or tendons.
6. Orthopedic/Neurological Testing:  these are standard tests to access your neuro-, musculo-, and skeletal systems.

NOTE:  This examination process is imperative to properly diagnose and treat your condition.  I ask that you comply to the best of your ability and report changes in your pain.  All procedures are accomplished to your tolerance.

I understand the above statement and agree to submit to all procedures as well as accept the risks and consequences of their application.

The undersigned parent(s)/legal guardian(s) hereby grant Griffin Family Wellness the authority to provide medical, chiropractic, and/or physical therapy treatment for the above mentioned patient.  This grant of temporary authority shall begin at the time of the initial visit and remain effective until terminated by the undersigned.

PATIENT’S RIGHTS                                                                                                                                 

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY. 

Griffin Chiropractic, Inc is required, by law, to maintain the privacy and confidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information.

TREATMENT

We may disclose your health care information to other healthcare professionals within our practice for the purpose of treatment, payment or healthcare operations. (example)

“on occasion, it may be necessary to seek consultation regarding your condition from other health care providers associated with Griffin Family Wellness.”

“It is our policy to provide a substitute health care provider, authorized by Griffin Family wellness to provide assessment and/or treatment to our patients, without advanced notice, in the event of your primary health care provider’s absence due to vacation, sickness, or other emergency situation.”

PAYMENT

We may disclose your health information to your insurance provider for the purpose of payment or health care operations. (example)

“As a courtesy to our patients, we will submit an itemized billing statement to your insurance carrier for the purpose of payment to Griffin Family wellness for health care services rendered.  If you pay for your health care services personally, we will, as a courtesy, provide an itemized billing to your insurance carrier for the purpose of reimbursement to you.  The billing statement contains medical information, including diagnosis, date of injury or condition, and codes which describe the health care services rendered.”

WORKERS’ COMPENSATION

We may disclose your health information as necessary to comply with State Workers’ Compensation Laws.

PUBLIC HEALTH

As required by law, we may disclose your health information to public health authorities for purposes related to:  preventing or controlling disease, injury or disability, reporting child abuse or neglect, reporting domestic violence, reporting to the Food and Drug Administration problems with products and reactions to medications, and reporting disease or infection exposure.

JUDICIAL AND ADMINISTRATIVE PROCEEDINGS

We may disclose your health information in the course of any administrative or judicial proceeding. 

LAW ENFORCEMENT

We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena, and other law enforcement purposes.

DECEASED PERSONS

We may disclose your health information to coroners or medical examiners.

ORGAN DONATION

We may disclose your health information to organizations involved in procuring, banking, or transplanting organs or tissues.

RESEARCH

We may disclose your health information to researchers conducting research that has been approved by and Institutional Review Board.

PUBLIC SAFETY

It may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public.

SPECIALIZED GOVERNMENT AGENCIES

We may disclose your health information for military, national security, prisoner and government benefits purposes.

MARKETING

We may contact your for marketing purposes or fund-raising purposes, as described below: (Example)

 “As a courtesy to our patients, it is our policy to call/text/email you prior to your scheduled appointment to remind you of your appointment time.  If you are not available, we leave a reminder message on your answering maching or with the person answering the phone.  No personal health information will be disclosed during this recording or message other than the date and time of your scheduled appointment along with a request to call our office if you need to cancel or reschedule your appointment.”

CHANGE OF OWNERSHIP

In the event that Griffin Family Wellness is sold or merged with another organization, your health information/record will become the property of the new owner

YOUR HEALTH INFORMATION RIGHTS

• You have the right to request restrictions on certain uses and disclosures of your health information.  Please be advised, however, that Griffin Family Wellness is not required to agree to the restriction you requested.
• You have the right to have your health information received or communicated through and alternative method or sent to an alternative location other than the usual method of communication or deliver, upon your request.
• You have the right to inspect and copy your health information
• You have a right to request that Griffin Family Wellness amend your protected health information.  Please be advised, however, that Griffin Family Wellness is not required to agree to amend your protected health information.  If your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s) and information about how you can disagree with the denial.
• You have a right to receive an accounting of disclosures of your protected health information made by Griffin Family Wellness
• You have a right to a paper copy of this Notice of Privacy Practices at any time upon request.

CHANGES TO THIS NOTICE OF PRIVACY PRACTICES

Griffin Family Wellness reserves the right to amend this Notice of Privacy Practices at any time in the future, and will make the new provisions effective for all information that it maintains.  Until such amendment is made, Griffin Family Wellness is required by law to comply with this notice.

Griffin Family Wellness is required by law to maintain the privacy of your health information and to privide you with notice of its legal duties and privacy practices with respect to your health information.  If you have questions about any part of this notice or if you want more information about your privacy rights, please contact Griffin Family Wellness by calling this office at 661-505-6303.  If Dan Griffin, DC is not available you may make an appointment for a personal conference in person or by telephone within 2 working days.

COMPLAINTS

Complaints about your privacy rights, or how Griffin Family Wellness has handled your health information should be directed to Dan Griffin, DC by calling this office at 661-505-6303.  If Dan Griffin, DC is not available, you may make an appointment for a personal conference in person or by telephone within 2 working days.

If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to:

                                   DHHS, Office of Civil Rights

                                   200 Independence Avenue, S.W.

                                   Room 509F HHH Building

                                   Washington, DC  20201

I have read the privacy notice and understand my rights contained in this notice.

By way of my signature, I provide Griffin Family Wellness with my authorization and consent to use and disclose my protected health care information for the purposes of treatment, payment and health care operations as described in the Privacy Notice.

AUTHORIZATION AND ASSIGNMENT OF BENEFITS

1. I authorize the RELEASE OF ANY INFORMATION concerning my health to any insurance company, attorney or adjuster necessary to process any claim for payment of Griffin Family Wellness’ charges incurred by me.  I authorize the insurance company to furnish Griffin Family Wellness with any information regarding my claim under the policy or social security act.
2. In consideration of Griffin Family Wellness’ rendering of treatment to me without immediate compensation therefore I authorize and IRREVOCABLY ASSIGN MY RIGHT TO PAYMENT of Griffin Family Wellness’ bill for treatment rendered to me out of the proceeds of any judgment, settlement in my case and furthermore, from any insurance company providing coverage to me for such purposes.
3. With reference to any contracted insurance providing coverage to me for Griffin Family Wellness’ treatment, I understand, authorize and agree that no payments due me under said contract of insurance shall be made to me for any other medical expenses incurred until GRIFFIN FAMILY WELLNESS’ BILL FOR TREATMENT IS FIRST PAID IN FULL.
4. I give assignment and lien in any claims against a third party whose negligence may have caused my injury, up to the amount of the bill for treatment.
5. In the event any insurance company obligated by contractual agreement to make payment to make payment to me or to Griffin Family Wellness refuses to make such payment upon demand, I hereby IRREVOCABLY ASSIGN AND TRANSFER to Griffin Family Wellness any CAUSE OF ACTION that exists in my favor against any such company, and authorize Griffin Family Wellness to prosecute that action either in my name or in Griffin Family Wellness’ name and further compromise, settle or otherwise resolve said claim.
6. I waive the STATUTE OF LIMITATIONS regarding Griffin Family Wellness’ right to recover.
7. I permit a COPY OF AUTHORIZATION to be used in place of the original.
8. I hereby appoint Griffin Family Wellness’ duly authorized agents and employees, to endorse any and all checks, drafts or money orders, which are made payable to the undersigned, for medical services or the like which have been, or are to be, performed by Griffin Family Wellness’ duly authorized agents and employees.

NOTICE TO INSURANCE COMPANY OF ASSIGNMENT    

You are instructed to PAY DIRECTLY TO GRIFFIN FAMILY WELLNESS for all professional services rendered to me by their office.

This instruction to you is an assignment of my rights under the medical coverage of the insurance policy or my right under the third party liability claim.

Any sum of money paid under this assignment shall be credited to my account

To the patient:  Please read this entire document prior to signing it.  It is important that you understand the information contained in this document.  Please ask questions before you sign if there is anything that is unclear.

The nature of the chiropractic adjustment

The primary treatment I use as a Doctor 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.  This 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 part of the analysis, examination and treatment, you are consenting to the following procedures.

- Spinal Manipulative Therapy	- Postural analysis
- Range of motion testing	- EMS
- Muscle strength testing	- Myofascial release
- Hot/cold therapy	- Vital Signs
- Exercise therapy	- Basic neurological testing
- Cupping therapy	- Ultrasound
- Palpation	- Mechanical therapy
- Orthopedic testing	- Massage therapy

The material 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 and separations and burns.  Some types of manipulations 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.  I 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 my attention, it is your responsibility to inform me.

The probability of those risks occurring.

Fractures are rare occurrences and generally result from some underlying weakness of the bone which I check for during the taking of your history and during examination.  Stroke has been the subject of tremendous disagreement.  The incidences of stroke are exceedingly rare and are estimated to occur between one in one million and one in five million cervical adjustments.  The other complications are also generally described as rare.

 

The availability 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 pain killers
• Hospitalization
• Surgery

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 you 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.

 

DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE. 

I have read or have had read to me the above explanation of the chiropractic adjustment and related treatment.  I have discussed it with Dan Griffin, DC and have had my questions answered to my satisfaction.  By signing below I state that I have weighed the risks involved in undergoing treatment and have decided that it is in my best interest to undergo the treatment recommended.  Having been informed of the risks, I hereby give my consent to that treatment.