Employment / Student Information
Assignment and Release
I certify that I, and/or my dependent(s), have insurance coverage with the above insurance company, and assign directly to Dr. Son Nguyen, DC all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The Doctor(s) may use my health care information and may disclose such information to the above - named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.
Personal Health History
List any operations, surgeries, or medical procedures:
Welcome to Seminole Chiropractic Medicine. We strive to provide you with excellent Chiropractic care and our goal is to make your visits as convenient as possible.
By signing below, you confirm that you have read this policy and understand that:
If you have Health Insurance Coverage : As a courtesy to you, we will attempt to pre - verify your insurance coverage for your Chiropractic care. Coverage information is obtained from your insurance company using information provided by you prior to your initial visit. We must emphasize that as medical providers, our relationship is with you, not your insurance company. Please be advised that the information provided by your insurance company is not a guarantee of payment, only an estimate of what might be covered under your policy at the time of inquiry.
By signing below, you confirm you understand that:
By signing below, you have read and understand the above Financial Policy and agree to meet all financial obligations.
By signing below, you acknowledge that you have received a copy of our Notice of Privacy Practices.
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 Dr. Son Nguyen, DC and/or other licensed Doctors of C hiropractic who now or in the future treat me while employed by, working, or associated with or serving as back - up for Dr. Son Nguyen, DC including those working at the clinic or office listed below or any other office or clinic.
I will have/had an opport unity to discuss with Dr. Son Nguyen, DC and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and other procedures.
I understand and am informed that, as in the practice of medicine, in the practice of chiropract ic there are some risks to treatment including, but not limited to, fractures, disk injuries, strokes, dislocations, and sprains. I do not expect the do ctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgement during the course of the procedure which the doctor feels at the time, based upon the facts then known, is in my best interest. I understand that I have the right to seek other healthcare professionals for my condition and treatment.
This is to confirm that I have been advised by the Doctor that x - rays can be hazardous to an unborn child. At this time, to the best of my knowledge, I am not pregnant, and I consent to chiropractic treatment and radiographic pictures.
I hereby authorize the Doctor to examine and treat as deemed necessary, my
(indicate relations hip of child).
I understand and am informed that my insurance company may not/does not cover the medical treatment recommended by Dr. Nguyen DC; and that I am responsible for payment of those charges at the ti me of service.
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