Intake Forms

We would like to take a moment to welcome you to our office at Body of Beverly Hills Wellness, Inc and we assure you that you will receive the very best of care available for your condition(s). To familiarize you with the financial policy of this office, we would like to explain how your health care bills will be handled.

Explanation of Insurance Coverage:

Many insurance policies do cover chiropractic, acupuncture, massage therapy, physical therapy, physiotherapy or may cover other services rendered by our office for care but this office makes no representation that yours does. Insurance policies may vary by plan greatly in terms of deductible and percentage of coverage for care. Because of the variance from one insurance policy to another, we require that you, the patient, be personally responsible for the payment of your deductibles as well as any other unpaid balances in this office. We will do our best to verify your insurance coverage, and will bill your insurance in a timely manner as a courtesy to you.

Assignment of Benefits

By signing this form, you are authorizing payment of medical benefits will be made directly to this office. If your insurance carrier sends payment to you for services incurred in this office, you agree to send or bring those payments to this office upon receipt. However, if you pay for your visits in full the assignment will not be reported by this provider and any payment will be sent directly to you.

Release of Information

If your insurance company requires medical reports or records to document your treatment or progress, your signature below authorizes this office to release the medical information necessary to process your claim(s).

Voluntary Termination of Care

If you or the office suspends or terminates your care at any time, your portion of all charges for professional services is immediately due and payable to this office.  All services rendered by this office are charged directly to you, and you, ultimately will be personally responsible for payment regardless of your insurance coverage.

Balance/Surprise Billing Rights

I understand that I will have a financial responsibility applicable to my health care services provided by an out-of-network professional (provider). I understand that I am responsible for my copayment, deductible, coinsurance and that I may be responsible for any costs in excess of those allowed by my health benefits plan.

We are required to provide you with a “Good Faith” estimate of what those charges might be so there is no surprise balance of monies owed. Please be advised the chart below is only an example of an EOB (explanation of benefits) and does not reflect your insurance policies coverage of benefits.

 

Service	CPT Code	Fee	Estimated Payment	Estimated balance
Examination	99203	$250.00	$130.00	$120.00
Chiropractic Adjust	98941	$100.00	$47.50	$52.50
Traction	97012	$45.00	$18.00	$27.00
Massage	97124	$30.00	$15.00	$15.00
Manual Therapy	97140	$80.00	$30.00	$50.00
Exercise	97110	$80.00	$30.00	$50.00
Electrical M. Stim.	97014	$45.00	$14.00	$31.00
Therapeutic Activities	97530	$100.00	$24.00	$76.00

 

I have read and agree to the above and made aware that you are obtaining treatment by an “Out-of-network provider and are fully responsible for the cost of your care regardless of your plan details”.

I, the undersigned patient, acknowledge receipt of this disclosure form from my health care provider and have read it and understand the contents. I understand it is my option to obtain treatment with other health care providers, service providers, or alternative health care facilities that may participate with my health plan and I waive the right to do so and wish to obtain my treatment at this office with full notice of these disclosures and potential cost-sharing consequences. I have a right to contact my health insurance plan or administrator for further consultation on the costs or allowances of the above services.

By signing below, you fully agree to the terms and disclosures above. If you like a copy of this agreement, please inform the office.

You are the decision maker for your health care. part of our role is to provide you with information to assist you in making informed choices. This process is often referred to as “informed consent” and involves your understanding and agreement regarding the care we recommend, the benefits and risks associated with the care, alternatives, and the potential effect on your health if you choose not to receive the care

I, hereby request and consent to the performance of any services provided to me whether by a licensed chiropractor, acupuncturist, massage therapist, physical therapist, chiropractic assistant or any other licensed instructor on behalf of my care to conduct treatments that consist of various forms of adjustments or procedures, including but not limited to various modes of physiotherapy, physical therapy, massage therapy, manual therapy, spinal decompression therapy, radial pressure pulse, cupping, ems training, body ems slimming, class IV laser therapy and diagnostic imaging on me (or on the patient named below, for whom I am legally responsible) by the recommended of either chiropractic, acupuncturist, massage therapist, chiropractic assistant, physical therapist or any other licensed physician or practitioner whom now or in the future will treat me while employed by working, associated with or serving as backup for the doctor(s) of desired treatment, including those working at the office. 

Chiropractic care centrally involves what is known as a chiropractic adjustment. There may be additional supportive procedures or recommendations as well. When providing an adjustment, we use our hands or an instrument to reposition anatomical structures, such as vertebrae. Potential benefits of an adjustment include restoring normal joint motion, reducing swelling and inflammation in a joint, reducing pain in the joint, and improving neurological functioning and overall well-being.

I have had the opportunity to discuss with the treating provider(s) or with other office personnel regarding the nature and purpose of my treatment(s) and or any other procedures. Please understand during any time of your treatment(s) there maybe examinations or tests conducted that will be carefully performed but may cause some discomfort.

Please understand there are some risks to care, including, but not limited to: muscle spasms, aggravating and/or temporary increase in symptoms, lack of improvement of symptoms, burns and/or scarring from electrical stimulation and from hot or cold therapies, including but not limited to hot packs and ice, fractures (broken bones), disc injuries, strokes, dislocations, strains, and sprains. With respect to strokes, there is a rare but serious condition known as an “arterial dissection” that typically is caused by a tear in the inner layer of the artery that may cause the development of a thrombus (clot) with the potential to lead to a stroke, chiropractic adjustment does not cause a dissection in a normal, healthy artery.

The reported association between chiropractic visits and stroke is exceedingly rare and is estimated to be related in one in one million to one in two million cervical adjustments.

I understand that results are not guaranteed and there is no promise to cure. I have read, or have had read to me, the above consent. I appreciate that it is not possible to consider every possible complication to care. I understand and intend this consent to cover the entire course of care from all providers in this office for my present and for any future condition(s) for of chiropractic, acupuncture, massage therapy or any other service provided to me that there are some risks in treatment, including, but not limited to fractures, dislocations, strokes and sprains. I do not need or expect the doctor or treating physician to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the procedure which the doctor feels at the time, based upon the then known, is in my best interests. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intended this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I may seek treatment.

SIGNATURE ON FILE
I authorize use of this information on all my insurance submissions. I authorize release of information to all my insurance companies. I understand that I am responsible for all my bills. I authorize my doctor to act as my agent in helping me to obtain payment from my insurance company. I authorize payment directly to my doctor. I permit a copy of this authorization to be used in place of the original. I authorize that I am responsible for payment of an office visit on all missed appointments lacking a 24 —hour cancel notice.

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that the doctor's office will prepare any necessary medical reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to the doctor's office will be credited to my account on behalf of my receipt. However, I clearly understand and agree that all services rendered to me will be immediately due and payable to Body of Beverly Hills Wellness, Inc I also understand that if I suspend or terminate my care and treatment any fees for professional services rendered to me will be immediately due and payable. I undersigned, affirmed, and declared that I have been advised by the doctor's office that the bringing of a fraudulent claim is a crime punishable by imprisonment and / or fine, and that the doctor's office will not treat and / or be part of such fraudulent claims and held responsible. I hereby authorize the doctor to examine and treat any / my conditions as he / she deems appropriate using chiropractic, acupuncture, massage therapy or physical therapy health care personnel. I give authority for all necessary procedures to be performed during my treatment. I also agree that I am responsible for all bills incurred at this office.

Family History:

Woman only:

Other Health Intake:

CHECK ANY OF THE FOLLOWING YOU HAVE HAD THE PAST 6 MONTHS:

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. Body of Beverly Hills Wellness, Inc 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.

Disclosure of Your Health Care 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.
Payment: We may disclose your health information to your insurance provider for the purpose of payment or health care operations.
Personal Injury: We may disclose your health information as necessary to comply with State Personal injury Laws.
Emergencies: We may disclose your health information to notify or assist in notifying a family member, Or another person responsible for your care about your medical condition or in the event of an emergency or of your death.
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 and tissues.
Research. We may disclose your health information to researchers conducting research that has been approved by an 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 you for marketing purposes or fundraising purposes.
Change of Ownership. If Body of Beverly Hills Wellness, Inc is sold or merged with another organization, your health information/ record will become the property of the new owner.

Your Health Information Rights

1. You have the right to request restrictions on certain uses and disclosures of your health information. Please be advised, however, Body of Beverly Hills Wellness, Inc that is not required to agree to the restriction that you requested.
2. You have the right to have your health information received or communicated through an alternative method or sent to an alternative location Other than the usual method of communication or delivery, upon your request.
3. You have the right to inspect and copy your health information.
4. You have a right to request that Body of Beverly Hills Wellness, Inc your protected health information. Please be advised, however, that Body of Beverly Hills Wellness, Inc 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.
5. You have a right to receive an accounting of disclosures of your protected health information made by Body of Beverly Hills Wellness, Inc,
6. 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
Body of Beverly Hills Wellness, Inc 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, Body of Beverly Hills Wellness is required by law to comply with this Notice. Body of Beverly Hills Wellness, Inc is required by law to maintain the privacy of your health information and to provide 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 Body of Beverly Hills Wellness, Inc by emailing at or visit our website https://www.bodyofbeverlyhillswellness.com/  any complaints about your privacy rights, or how Body of Beverly Hills Wellness, Inc has handled your health information should be directed to us by the email at. 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 way 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 This notice is effective from the date below. I have read the Privacy Notice and understand my rights contained in the notice. By way of my signature, I provide Body of Beverly Hills Wellness, Inc 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.