**If you have multiple chief complaints, please answer the following questions accordingly for each one.
CONSENT TO TREAT
Chiropractic examination and therapeutic procedures (including spinal and/or extremity adjustments, heat/cold application, mechanical traction and manual muscle therapy), exercises & therapeutic massage (including deep tissue manipulation, traction of extremities and spine, hydrotherapy, reflexology, and manual lymphatic drainage) are considered safe and effective methods of care. However, any procedure intended to help may have complications. While the chances of experiencing complications are small, it is the practice of the chiropractor and/or his staff to inform patients about them, depending on who performs the procedures to the patient.
These complications include, but are not limited to: soreness, inflammation, soft tissue injury, dizziness, burns and temporary worsening of symptoms. More serious complications are extremely rare. Additional information on side effects and complications is available upon request.
I have read and understand the above statements regarding treatment side effects. I authorize the providers at Mobility Plus Sports Rehab to provide healthcare services to me. I also understand that there is no guarantee or warranty for a specific cure or result.
We value and respect your time! We require a full 24-hour notice for cancellations to avoid incurring a fee. This allows our patients committed to their care, just like you, to have adequate access to our services.
Patients who reschedule or cancel with less than twenty-four (24) hour notice before the start of their appointment time will be billed a $65 fee.
Patients who fail to show up for a scheduled appointment will be billed a $95 fee.
At Mobility Plus, we also offer the option to donate your cancellation fee to a charitable cause! Each of our team members has chosen an organization that they hold near and dear to list below. If you prefer this alternative, you will be asked to choose one of the organizations and to present us with a receipt of donation within one week of your cancellation.
I understand that a full twenty-four (24) hour notice is not only appreciated, but also required, when rescheduling or cancelling an appointment.
I also understand that I will be directly charged (insurance will not cover late cancellation fees) for missed appointments that I do not cancel or reschedule according to the twenty-four (24) hour policy, and I agree to pay for as such.
Payment is due at the time of service. As a service to you, your insurance company will be billed. If we can estimate/document your coverage, we will ask you to pay at the time of each office visit the amount your insurance company will not pay. This may be a deductible, coinsurance percentage or co-payment.
We require a credit card to be kept on file. Cards are processed every Wednesday. You will be sent a link to an online patient portal called Patient Ally where you will be able to see what balances are due and schedule appointments.
If the information obtained from your insurance company is inaccurate, or services that were thought to be covered are not paid for, you may be informed of a balance due. Information from insurance companies is NOT a guarantee of benefits. You are responsible for all charges incurred while under care in this office. You will be expected to pay for all non-covered services, supplements or supplies at the time they are presented to you.
I authorize payment directly to Mobility Plus Sports Rehab for services rendered to me. I understand and agree that health and accident policies are a contract between my insurance company and me. I also understand that if my insurance provider refuses payment, my services are not billable to insurance or my deductible has not been met, I am directly and fully responsible to said provider for all bills submitted by them for services rendered to me. I understand that all payments are due at time of service. I also understand that verification of benefits prior to services rendered is my responsibility and some services may not be covered by my individual insurance policy. Payment for these services is my responsibility. I understand and agree that regardless of insurance coverage, I am liable for any charges incurred as a result of services rendered to me by the providers of Mobility Plus.
I understand as a patient of Mobility Plus Sports Rehab, that it is my responsibility to track how many chiropractic and physical therapy visits I have used and have remaining in my insurance plan. Mobility Plus Sports Rehab will provide an estimate of benefits at the start of my treatment, however, I understand it is my responsibility to verify that information and track my visits through my insurance company.
I understand that any balance remaining unpaid at the time of service will be billed to me. Any unpaid balances are subject to a $30 late fee for every 14 days the balance is past due from the first date of receipt of invoice.
I understand that in the event of a declined transaction, I will be notified by phone and email to provide an alternate method of payment. A $30 fee will be added to my balance if I do not provide an alternative payment method within 14 days.
FOR PIP AND L&I CLAIMS ONLY
If you have a personal injury claim, we will bill your auto insurance company. If you have a worker’s compensation claim, we will submit your claims to the state of Washington. If your claim is not covered 100%, you will be responsible for the difference. It is expected that if an attorney has been assigned to your case, a lien will be signed for assignment of benefits for services. If your account is assigned to an attorney for collection and/or suit due to delinquency, the prevailing party shall be entitled to attorney’s fees and cost for collection.
RELEASE OF PROTECTED HEALTH INFORMATION (PHI)
I give permission to my provider and staff to release information, verbal and written, contained in my medical record, and other related information, to my insurance company, case manager, attorney, and related healthcare provider. I understand that all release of information is contingent upon prior approval in writing by myself.
I authorize the release of records to third parties requiring records for determination of financial liability.
ACKNOWLEDGEMENT OF PRIVACY PRACTICES
We do not attach copies of our Privacy Practices to this form. The front desk staff will gladly provide you with a copy, or one can be found on our website at www.mobilityplussportsrehab.com
The Notice of Privacy Practices tells you how we may use and share your health records. Please read it.
All the ways we may use and share your health records are explained in more detail in the Notice of Privacy Practices.
You have the rights with respect to your health records:
All of these rights are explained in more detail in the Notice of Privacy Practices.
I consent to the use and sharing of my health records for treatment, payment, and operation purposes as described in the Notice of Privacy Practices. I know that if I do not consent, you cannot provide services to me. Washington law requires that we advise you that the information authorized for disclosure may include information which may be considered a communicable or venereal disease, including, but not limited to, Hepatitis, Syphilis, Gonorrhea, Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome (AIDS). It may also include mental health or other sensitive information.
I have read and understood all of the above.