Patient Information Form

I certify that I have read and I understand the question above. I acknowledge that my questions, if any, about the inquires set forth above have been answered to my satisfaction. I will not hold my Chiropractor, or any other member of his/her staff, responsible for any errors or omissions that I have made completion of this form. 

• We invite you to discuss with us any questions regarding our services. The best health services are based on a friendly, mutual understanding between provider and patient.
• Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with the business manager. If account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, interest charges and any other expenses incurred in collecting your account.
• I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider to release any information required to process insurance claims.

AUTHORIZATION AND RELEASE: I authorize payment of insurance benefits directly to the chiropractor or chiropractic office. I authorize the doctor to release all information necessary to communicate with personal physicians and other healthcare providers and payers and to secure the payment of benefits. I understand that I am responsible for all costs of chiropractic care, regardless of insurance coverage. I also understand that if suspend or terminate my schedule of care as determined by my treating doctor, any fees for professional services will be immediately due and payable.

The patient understands and agrees to allow this chiropractic office to use their Patient Health Information for the purpose of treatment, payment, healthcare operations, and coordination of care. We want you to know how your Patient Health Information is going to be used in this office and your rights concerning those records. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA Notice that is available to you at the front desk before signing this consent. If there is anyone that you do not want to receive your medical records, please inform the office.

I acknowledge that I have received/was offered, a copy of the Privacy Notice. 

I acknowledge that I have received a copy of the Financial Policy. I hereby authorize and assign directly to Koch Chiropractic & Holistic Pain Management all insurance benefits, if otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

I have read the explanation of chiropractic treatment. I have had the opportunity to have any questions answered to my satisfaction. I have fully evaluated the risks and benefits of undergoing treatment. I have freely decided to undergo the recommended treatment, and herby give my full consent to treatment. I have the right to withdraw my consent at any time, upon written notice. I have the right to refuse treatment at any time.

Release the Information-Please List Any Family or Friends We May Release Information To

• If you are unable to keep a scheduled appointment, please call our office to cancel with a 24 hour notice or as promptly as possible. This time will be given to someone who otherwise may have to wait days to be seen.
• A "No Show" is someone who misses an appointment without canceling it 24 hours in advance. No shows inconvenience everyone who need access to care in a timely manner.
• A failure to present at the time of a scheduled appointment is recorded in our appointment schedule as a "No Show." The first time there is a "No Show," the patient will be contacted by phone to try and reschedule the appointment. If there is a second "No Show," a fee of $40.00 will be billed to the patient, not the insurance company, and this fee is required to be paid before scheduling the patient's next appointment. Three "No Shows", may result in the termination from our practice.

**We do understand that unforeseeable events occur and may cause late cancellations and No Shows and we are willing to accommodate these situations on a case by case basis.**

Dear Patient,

The State of Wisconsin requires every patient be informed of the risks of treatment and the alternative to treatment prior to beginning treatment. The following is Koch Chiropractic & Holistic Pain Management informed consent. We intend this consent form to cover the entire course of treatment for your
present condition and for any future conditions for which you seek treatment at this office.

The Nature Of Chiropractic Treatment: In this offce we use trained staff to assist the doctor with portions of your consultation, examination, and treatment. Occasionally when your doctor is unavailable, another clinic doctor will treat you. The doctor will use her hands or a mechanical device in order to move your joints. You may hear a 'click' or a 'pop', similar to when a knuckle is 'cracked', and you may feel movement of the joint. Various ancillary procedures, Such as hot or cold packs, electric muscle stimulation, therapeutic ultrasound or traction, as well as exercise instruction may also be used.

Benefits of chiropractic treatment: Many or most patients will feel improvement in motion, decreased muscle and joint pain and improved well-being after a series of chiropractic adjustments.

Possible risks: As with any health care procedure, complications are possible following a chiropractic treatment. Complications could conceivably include muscular strain, ligamentous sprain, dislocations of joints, fracture of bone. or injury to intervertebral discs, nerves or spinal cord. A minority of patients may notice stiffness or soreness after the first few days of treatment. The ancillary procedures could produce skin irritation, burns or other minor complications. There are reported cases of stroke associated with visits to medical doctors and chiropractors. The best quality scientific evidence does not establish a cause and effect relationship between chiropractic treatment and the occurrence of stroke; rather it indicates that patients may be consulting medical doctors and/or chiropractors for symptoms of headache and neck pain when they are in the early stages of stroke. The possibility of such injuries occurring in association with chiropractic treatment is extremely remote.

Probability of risks occurring: The risks of complications due to chiropractic treatment have been described as "rare" to "extremely rare".

Other treatment options that could be considered may include the following:

• Over-the-counter analgesics. The risks of these medications include irritation to stomach, liver and kidneys, increased cardiovascular risk, and other side effects in a significant number of cases.
• Medical care, typically anti-inflammatory drugs, tranquilizers and analgesics. Risks of these prescription drugs include all side effects as above, plus patient dependence in a significant number of cases.
• Hospitalization in conjunction with medical care adds additional risk exposure to medical error, infection and other complications in a significant number of cases.
• Surgery in conjunction with medical care adds the risks of adverse reaction to anesthesia, as well as an extended convalescent period in a significant number of cases.

Risk of remaining untreated: Delay of treatment allows formation of adhesions, scar tissue and other degenerative changes. These changes can further reduce skeletal mobility, and induce chronic pain cycles. It is quite probable that delay of treatment will complicate the condition, and make further rehabilitation difficult,

Concerns Of questions: Please ask your Doctor of Chiropractic. We at Koch Chiropractic & Holistic Pain Management have gone to great lengths to make your health and safety our top priority. We will be glad to explain any concern about treatment you might have.

I have read the above explanation of chiropractic treatment. I have had the opportunity to have any questions answered to my satisfaction. I have fully evaluated the risks and benefits of undergoing treatment. I have freely decided to undergo the recommended treatment, and herby give my full consent to treatment. I have the right to withdraw my consent at any time, upon written notice. I have the right to refuse treatment at any time.

Other than the circumstances described in the preceding examples, any other use or disclosure of your health information will only be made with your written authorization.

Your individual rights

You have rights concerning the confidentiality of your health information. You have the right:

1. To request restrictions on the health information we may use and disclose for treatment, payment and health care operations. We are not required to agree to these requests. To request, please send a written request to us.
2. To receive confidential communications of health information. You must make such requests in writing to our office. However, we reserve the right to determine if we will be able to continue your treatment under such restrictive authorizations.
3. To inspect or copy your health information. You must make such requests in writing to our office. If you request a copy of your health information we may charge you a fee for the cost of copying, mailing or other supplies. In certain circumstances we may deny your request to inspect or copy your health information, subject to applicable law.
4. To amend health information. You have the right to request that we amend your health information for 7 years from the date that the record was created or as long as the information remains in our files. We require your request to amend your records be in writing and for you to give us a reason to support the change you are requesting us to make.
5. To receive an accounting of disclosures of your health information. You must make such requests in writing. Not all health information is subject to this request. Your request must state a time period for the information you would like to receive, no longer than 6 years prior to the date of your request. Your request must state how you would like to receive the report (paper, electronically).
6. To designate another party to receive your health information. If you request for access to your health information directs us to transmit a copy of the health information directly to another person the request must be made in writing and clearly identify the designated recipient and where to send the copy of the health information.

Your right to Complain 

If you think that we have not properly respected the privacy of your health information, you are free to complain to us or to the US Department of Health and Human services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person. If you prefer, you can discuss your complaint in person or by phone.

To Contact us

If you would like further information about our privacy policies and practices please contact:

KOCH CHIROPRACTIC
1990 GODFREY DR
WAUPACA, WI 54981
(715) 256-9616

Changes to this Notice:

We reserve the right to change our privacy practices and to apply the revised practices to health information about you that we already have. Any revision to our privacy practices will be described in a revised Notice that will be posted prominently in our facility. Copies of this Notice are also available upon request at our reception area.

Notice of Revised and Effective: March 3, 2020

Thank you for choosing Koch Chiropractic & Holistic Pain Management for your chiropractic needs. We appreciate the opportunity to serve you and are committed to providing you with the best possible care.

As part of our services to you, we try to contain the ever-rising cost of health care. In an effort to do this, we have implemented the following Financial Policy. Please read and sign below. Your cooperation in following our credit policy will allow for a prompt settlement of your claim.

Insurance:  Koch Chiropractic & Holistic Pain Management accepts assignment from many insurance companies. However; Insurance is a contract between you and your insurance company. We are NOT party to this contract. We will bill your primary insurance company as a courtesy to you. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final
determination of your eligibility. You agree to pay any portion of the charges for services rendered but not covered by plan paid (denied) by your insurance. Any services rendered after insurance edibility terminates will be charged at our standard fees.

Medicare/Medicaid:  Koch Chiropractic & Holistic Pain Management will accept assignment for Medicare or Medicaid. Patients are responsible for their co-payment and payment for any service not covered by Medicare/Medicaid. You agree to pay any portion of the charges for servics rendered but not covered by your plan or not paid (denied).

Workers' Compensation: Work-related injury cases are accepted on assignment with permission of the employer and prior authorization from the employer's compensation insurance carrier. You agree to pay any portion of the charges for services rendered but not covered by your plan or not paid (denied).

Patients WITHOUT Insurance Coverage: Patients without insurance coverage are required to pay for services as rendered. 

Payments: Unless other arrangements are approved by us, the balance on your statement is due and payable when the statement is issued, and is past due if payment is not received within 30 days.

Payment Options: You may pay by cash, check, MasterCard, Visa, Discover cards.

Returned checks: There is a fee (currently $35.00) for any checks returned by the bank. Returned checks not redeemed within 21 days will be turned over to collection and associated costs will be added to the balance due.

Divorce: In case of divorce or separation, the parent accompanying the child and authorization treatment will be the parent responsible for the charges on the day of service. if the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent's responsibility to collect from the other parent

Past due accounts: If your account becomes past due, we will take necessary steps to collect this debt. If we have to refer your account to a collection agency, or to a lawyer, you agree to pay all of the collection costs, lawyers' fees plus all court costs which are incurred. In case of a suit, you agree that the venue be in Waupaca County, Wisconsin.

Effective Date: Once you signed this agreement, you agree to all of the terms and conditions contained herein and the agreement will be in full force and effect.

This is an agreement between Koch Chiropractic & Holistic Pain Management, and the Patient named on this form.

By executing this agreement, you are agreeing to pay for all services that are received, and agree to all the terms listed above.

We are very concerned with protecting your privacy. While the law requires us to give you this disclosure, please understand that we have, and always will, respect the privacy of your health information. 

Uses and Disclosures

The most common reason why we use or disclose your health information are for treatment, payment or health care operations.

Here are some examples of how we might use or disclose your health information:

1. Our office may have to disclose your health information including all of your clinical records to another health care provider or a hospital if it is necessary to refer you to them for diagnosis, assessment, or treatment of your health condition.
2. Our office may have to disclose your examination and treatment records and your billing records to another party, such as an insurance carrier, HMO, PPO, or your employer, if they  are potentially responsible for the payment of your services.
3. Our office may need to use your health information, examination and treatment records and your billing records for quality control purposes or for other administrative purposes to efficiently and effectively run our practice.
4. Our office may need to use your name, address, phone number, and your clinical records to contact you to provide appointment reminder, information about treatment alternative, or other health related information that may be of interest to you. If you are
   not at home to receive an appointment reminder, a message will be left on your answering machine.

Your right to limit users or disclosures

You have the right to request that we do not disclose your health information to specific individuals, companies, or organizations. If you would like to place any restrictions on the use or disclosure of your health information, please let us know in writing. We are not required to agree to your restrictions. However, if we agree with your restrictions, the restriction is binding on us.

Your right to revoke your authorization

You may revoke your consent to us at any time; however, your revocation must be in writing. We will not be able to honor your revocation request if we have already released your health information before we receive your request to revoke your authorization. If you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they decided to contest any of your claims.

Permitted use and disclosure without your consent or authorization

In some limited situations, the law allows or requests us to use or disclose your health information without your consent or authorization.

Such disclosures are:

1. When a state or federal law mandates that certain health information be reported for a specific purpose.
2. For public health purposes, such as contagious disease reporting, investigation or surveillance, and notices to and from the federal Food and Drug Administration regarding drugs or medical devices.
3. To governmental authorities about victims Of suspected abuse, neglect or domestic violence.
4. For health oversight activities, such as for the licensing of doctors; audits by Medicare and Medicaid; or for investigation of possible violations of health care laws.
5. For judicial and administrative proceeding, such as a response to subpoenas or orders of courts or administrative agencies.
6. For law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else.
7. To appropriate law enforcement authority; in an event to prevent or lessen a serious and  imminent threat to the health or safety of a person or the public.
8. To a correctional institution if we provide health care services to you as an inmate.
9. When we provide health care services to you in an emergency.
10. When your care is related to a workers compensation injury.