I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic x-rays, on me (or on the patient named below, for whom I am legally responsible) by the doctor of chiropractic and / or other licensed doctors of chiropractic who now or in the future treat me while employed by, working or associated with or serving as backup for the doctor of chiropractic named above, including those working at the clinic or office listed above or any other office or clinic.
I have had the opportunity to discuss with the doctor of chiropractic and / or with other office or clinic personnel the nature and of chiropractic adjustments and other procedures. I understand that results are not guaranteed.
I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment, including, but not limited to fractures, dislocations, strokes and sprains. I do not need or expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of 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 pæsent condition and for any condition(s) for which I may seek treatment.
CONSENT TO TREATMENT OF MINORI (we) being the parent(s) of Type a label , a minor, the age of Type a label years, do hereby consent, authorize and request Kaliko Chiropractic, Dr. Micheal Kaliko, and whomever he may designate as his assistant to administer treatment as he/she so deems necessary on the above minor. I agree to hold him free and harmless from my claims, suits of damages or complications, which may result from 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 direct 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 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 receipt. However, I clearly understand and agree that all services rendered to me will be immediately due and payable. I also understand that if I suspend or terminate my care and treatment any fees for professional services rendered me will be immediately due and payable. I, the undersigned, affirm and declare 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. I hereby authorize the Doctor to examine and treat any condition as he / she deems appropriate through the use of Chiropractic Health Care. I give authority for all of these procedures to be performed. It is understood and agreed the amount paid the Doctor for X-ray negatives will remain the property of this office. I also agree that I am responsible for all bills incurred at this office.
PLEASE CHECK OR DESCRIBE:
Below are the list of diseases which may seem unrelated to the purpose of your appointment, However, these questions must be answered carefully as these problems can affect your overall course of care.
CHECK ANY OF THE FOLLOWING YOU HAVE HAD THE PAST 6 MONTHS:
Rate your current difficulties, resulting from your accident/illness, with regard to the various activities listed below. Use the following 1 to 5 scale.
Select the appropriate number that most closely describes your current degree of difficulty:
1="I can do it without any difficulty"
2="I can do it without much difficulty, despite some pain"
3="I manage to do it by myself, despite marked pain"
4="I manage to do it, despite the pain, but only if I have help"
5="I cannot do it all, because of the pain"
Only fill in areas affected.
Difficulties with Self Care and Personal Hygiene Activities
Difficulties with physical activities
Difficulties with Functional Activites
Difficulties with Social and Recreational Activities
Difficulties with Travelling
Use the following 1 to 5 scale to describe the difficulties below:
1="This area is not affected by my codition"
2="This area is slightly affected by my condition"
3="My condition moderatley restricts my ability in this area"
4="My condition seriously limits my ability in this area"
5="My condition prevents me from using this ability"
Difficulties with Different Forms of Communication
Difficulties with the Senses
Difficulties with Hand Functions
Difficulties with Sleep and Sexual Function
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. Kaliko Chiropractic 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. Workers' Compensation We may disclose your health information as necessary to comply with State Workers' Compensation 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.Reasearch.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. MarketingWe may contact you for marketing purposes or fundraising purposes. Change Ownership. In the event that Kaliko Chiropractic is sold or merged with another organization, your health information/ record will become the property of the new owner.
Your Health Information Rights
Changes this Notice Of Privacy Practices Kaliko Chiropractic 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, Kaliko Chiropractic is required by law to comply with this Notice. Kaliko Chiropractic 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: Judy Strohfrldt by calling this office at (310) 855-9899. If Ms. Strohfeldt 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 Kaliko Chiropractic has handled your health information should be directed to Judy Strohfeldt by calling this office at (310) 855-9899 If Ms. Strohfeldt 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
This notice is effective as of Date I have read the Privacy Notice and understand my rights contained in the notice. By way of my signature, I provide Kaliko Chiropractic with my authorization and consent to use and disclosed my protected health care information for the purposes of treatment, payment and health care operations as described in the Privacy Notice.