To be completed by the patient or patient’s representative, necessary, (eg: if the patient is a minor or is physically or mentally incapacitated)

PATIENT FINANCIAL POLICY
Thank you for choosing Kansas Acupuncture & Chiropractic Clinic as your health care provider. We are committed to providing excellent care to all of our patients, and we will always do our best to achieve this goal in the clinic. As in most medical practices, medical fee reimbursements continue to decrease while our costs continue to increase. We have implemented the Patient Financial Policy to help control costs so that we can always provide high-quality medical care. We are happy to assist you by billing your insurance company and requesting that your insurance company remit the payments directly to our office. I do hereby authorize Kansas Acupuncture and Chiropractic Clinic to pursue claims and exercise all rights in order to collect insurance payments that result of the services I received from KAC Clinic. All future HCFA claim forms will read “signature on file” in box 13 and shall constitute authorization to accept this as a current and valid signature on file for all future claim forms submitted. I understand that any explanation of eligibility, coverage or benefits by KAC clinic staff is not a guarantee of payment by my insurance provider and that I am responsible for the annual deductible, copay(s) and any co-insurance requirements at the time of treatment. I also understand that I am fully financially responsible for any fees of services provided by Dr. Taejeon Shin and clinic personnel, including fees that are not covered or are denied by my insurance (if applicable). Please note that if an ”Explanation of Benefits” EOB shows the patient’s outstanding responsibility for any reason, patient will receive a bill outlining the outstanding charges. Payment is due within 30 days of receipt of the bill and any dispute must be notified within 30 days of receipt of the bill too. In event of further action is necessary for overdue accounts, a collection fee, attorney fee, and court costs incurred will be paid by the patient. Our clinic collects $25 for each returned check to cover bank transaction fee.

I hereby request and consent to the performance of oriental medicine treatments including acupuncture, chiropractic adjustments (diversified and activator technique) and other chiropractic procedures including various modes of physical therapy, supplements and if necessary, diagnostic x-rays on me by the chiropractic physician and/or anyone working in this office authorized by the chiropractic physician. I further understand that such chiropractic and oriental medicine services may be performed by the Physician of Chiropractic named here Dr. Shin, Taejeon and/or other licensed Physicians of Chiropractic who may treat me now or in the future at this office. I understand that results are not guaranteed. I understand and am informed that, as in the practice of medicine and all healthcare, the practice of chiropractic and oriental medicine carries some risks to treatment; including, but not limited to: bruising, soreness, dizziness, nausea, fractures, disc injuries, dislocations, sprains, burns and in rare cases stroke (CVA). I do not expect the physician to be able to anticipate and explain all risks and complications. Further, I wish to rely on the physician to exercise judgment during the course of the procedure(s) which the physician feels are in my best interests at the time, based upon the facts then known. Alternative procedures also have ben explained to me including rest, oriental medicines, supplements, and home applications of therapy like ice, heat, & exercises. Rest, herb medication and supplements can help reduce pain and inflammation. It is same with ice and heat therapy at home. Exercises are not corrective of injured nerve and joint tissues but help strengthen and stretches surrounding muscles help with the treatment. With that explanation, I understand the potential risks of refusing or neglecting care may increase pain, scar/adhesion formation, restrict motion, possible nerve damage, increased inflammation, and worsening the condition which will result difficult and prolonged rehabilitation.