Cirlce the number below to indicate your level of pain
The following questions pertain to the other vehicle invloved in the accident:
If yes, please provide a copy of the police report that was filed.
Assignment of benefits for personal injury or motor vehicle accident.
I hereby assign all medical benefits, to include all major medical benefits to which I am entitled to Avise Chiropractic.
I understand that I am responsible for all charges, whether or not paid by stated insurance; I hereby authorize said assignee to release any and all information necessary to secure payment. If I have personal injury protection (PIP) or Med Pay through my automobile insurance, Avise Chiropractic will bill my insurance carrier directly, as long as my PIP/MP claim application has been filed. If no application has been filed, Avise Chiropractic will bill me directly, as I am responsible for payment of all services rendered.
If I do not have PIP/MP coverage and the other party is clearly at fault, as stated on the police report, a lien will be filed to secure payment to Avise Chiropractic, PLLC for the treatment of my injuries.
At our office we offer Chiropractic Care to treat Vertebral Subluxations. We do not offer to diagnose or treat any disease or condition other than subluxations. However, if during the course of an examination we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice for those findings we will recommend you to a provider who specializes in that area. OUR ONLY PRACTICE OBJECTIVE is to eliminate major interference through a specific chiropractic adjustment to correct the vertebral subluxation. If you need to spend extra time discussing your health with the doctor, please let our staff know so that we may schedule your next appointment accordingly.
I Name have read and understand the above statements. All my questions regarding the doctor's objectives pertaining to my care have been answered to my complete satisfaction. Initial *In order to diagnose subluxation the doctor may take x-rays. I certify to the best of my knowledge I am not pregnant and the doctor has my permission to perform an x-ray. I have been advised that an x-ray can be hazardous to an unborn child.I Name certify that there NO chance of pregnancy. Initial
Keeping your appointments is vital to getting you back on track and healthy. We do not charged for missed appointments for chiropractic but ask that you immediately call to reschedule. When arriving for your appointments please go to the front desk and sign in. This will help us to keep you on time and to the appointed doctor or therapist. Initial
To reduce confusion and misunderstandings between patients and the practice, we have adopted the following financial policies: All copayments, deductibles and non insurance covered charges must be paid at time of service. Initial We will prepare and send all claims to your insurance on your behalf. Initial There will be a $25 charge for any NSF in addition to any charges from you financial institution. Initial I have read and understand the Terms of Acceptance, Financial and Office Policies and agree to the above terms. I also understand that the practice may amend the terms from time to time.
Treatment of a Minor
For all services rendered to a minor, we will look to an adult to accompany the patient and for payment of any fees or services.I Name being the parent or legal guardian of have read and fully understand the terms above and hereby grant my permission for my child to receive Chiropractic care.
Your authorization is requested for purposes of delivering your care in an open adjusting or open door adjusting environment as described in the office's privacy notice.
In the course of your care either of these environments may cause details of your condition and care to be disclosed to other patients or staff in the approximate vicinity of where your care is being delivered. We cannot assure that any of the details ofyour care will be addressed and considered as confidential by other patients.
This authorization has been requested by Darren J. Avise, Avise Chiropractic, PLLC. The purpose of this authorization is to allow for phone/reminders at home/ work and your signature on a sign in sheet.
We are requesting your authorization in these regards to assure that you are fully informed and in agreement with the method and circumstances in which we deliver chiropractic care. Your care will not be conditioned on your agreement to this authorization. You have the right to not sign this authorization and you also have the right to revoke this authorization at some time in the future please advise us accordingly in writing.
If you agree to this authorization copy will be maintained by this office and a copy will be provided to you.
Thank you for your cooperation and understanding.