To Our Patients:

Chiropractic examination and therapeutic procedures (including spinal adjustment, ultrasound, heat application, electrotherapy, and manual muscle therapy) are considered safe and effective methods of care. Occasionally, however, complications may arise. Any procedure intended to help may have complications. While the chances of experiencing complications are small, it is the practice of this clinic to inform our patients about them. Side effects include but are not limited to soreness, inflammation, soft tissue injury, dizziness, burns, and temporary worsening of symptoms. More serious complications are extremely rare, and their association with spinal adjustments (manipulation) is debated. These complications include injury to the arteries in the neck, which may be associated with stroke and serious neurologic impairment, injuries to the spinal disc, and spinal fractures. Serious complications are estimated to be in the range of 0.5-2 incidents per million adjustments of the neck and 1 per million for adjustments of the lower back. Additional information on side effects, complications, and effectiveness of spinal adjustments is available upon request.

I, , consent to Health and Wellness Chiropractic Center (HWCC) to use and disclosure of my Protected Health Information for the purpose of providing treatment to me, for purposes relating to the payment of services rendered to me. I understand that HWCC’s diagnosis or treatment of me may be conditioned upon my consent, as evidenced by my signature on this document.

For purposes of this consent, “Protected Health Information” means any information, including my demographic information, created or received by HWCC that related to my past, present, or future physical or mental health condition; the provision of health care to me; or the past, present, or future payment for the provision of health care services to me; and that either identifies me or from which there is a reasonable basis to believe the information can be used to identify me.

I understand I have the right to request a restriction on the use and disclosure of my Protected Health Information for the purposes of treatment, payment, or healthcare operations of HWCC, but that HWCC is not required to agree to these restrictions. However, if HWCC agrees to a restriction that I request, the restriction is binding on HWCC.

I have been given the opportunity to review HWCC’s Notice of Privacy Practices prior to signing this document. The Notice of Privacy describes my rights and the practice’s duties regarding the types of uses and disclosure of my Protected Health Information. This document is posted in plain view on the front desk near the intake window. Please notify our front desk if you wish to have a copy of our Notice of Privacy Practices.

I have the right to revoke this consent, in writing, at any time, except to the extent that the Physician or HWCC has acted in reliance on this consent.

We believe that all patients deserve the utmost respect and optimal care. We are here to help you, giving you the best care you deserve for a speedy recovery. Should you have any concerns, please exercise your rights as follows:

1. Voice your grievances or concerns about your care or about the manner in which you were treated by the staff. If you have concerns about your care, please contact your caring physician.
2. Receive clear and complete information about your care and participate in the decision concerning your treatment. If you have concerns about the front desk staff, insurance, or billing, please contact your caring Physician.
3. Be treated with respect and courtesy by all those involved in providing care and information.
4. Privacy during interviews and examinations. All information about a patient’s care and records will be treated in a confidential manner.

1. Please be as accurate and complete as possible when providing information about your medical history or condition.
2. Please read and cooperate with the instructions provided by your doctor.
3. Please ask for clarification about any aspect of your health care benefits that you do not fully understand.
4. Please keep scheduled appointments or give adequate notice of delay or cancellation.

I have read and understood the above statements regarding my rights and responsibilities.

This authorization must be written, dated, and signed by the patient or by a person authorized by law to give authorization.

I authorize at , to use and disclose a copy of the specific health information described below regarding:

, ,

All payments are due at the time of service unless special arrangements have been agreed upon prior to the visit.

All copay will be due at the time of service once your insurance coverage has been verified and we have established your financial responsibility.

As a courtesy to our patients, we will bill your insurance company for you. Please keep in mind that if there is a discrepancy, we will let you know as soon as possible; however, we will not get involved with any dispute between you and your insurance carrier.

If you have a credit balance, we will reimburse you after payment has been received.

All workers' compensation cases will be billed directly to the insurance company, provided the appropriate paperwork has been filled out, and a claim is filed. If the claim is denied, we will bill your private insurance carrier if you have coverage. Please keep in mind that if your claim is denied, you are responsible for prompt payment of your account.

Personal injury and auto accident cases will be billed to your auto insurance company, providing that a claim has been filed and the appropriate paperwork has been done. With your signature below, you assigned your insurance company as the payer on your behalf.

Keep in mind that we do not do third-party billings to your insurance companies.

If you choose not to file a claim with your auto insurance company or are uninsured, your account will be treated as a cash account; you will be responsible for the balance owed.

If a check is returned to our clinic due to insufficient funds, the payer will be notified, and full restitution is expected, including an insufficient fund charge of $50.00. The payer will have thirty (30) days to make restitution. If this amount is still owed after thirty (30) days, a penalty of $20.00 will be assessed to the administrative fee and 5% monthly interest.

We do not have a split fee schedule; all itemized charges are equal. However, all accounts pay at the time of service and require no billing will be eligible for a 50% discount. All massages will have an hourly rate of $90 USD, if and only if paid at the time of service.

*** ** We reserve the right to give free itemized services* *** *

In consideration and exchange for not having to immediately pay a debt owed and in consideration for receiving future care at or by the clinic and doctors on whose letterhead this document is printed (hereinafter “Clinic”), I, the undersigned, hereby assign and convey to the clinic a legal and equitable interest in any and all causes of action or rights of recovery I may have arising out of that certain accident or injury-producing event which occurred on or about the day of , 20 , to the full extent of the cost of treatment provided or to be provided to me by the clinic.

I hereby authorize and direct my attorney(s) to hold in trust and to pay directly to the clinic such sums as may be due and owing to the clinic for treatment and other professional services rendered me both by reason of this accident and by reason of any other bills that are due to the clinic and to withhold such sums from any settlement, judgment or verdict as may be necessary to adequately pay and protect the clinic. I hereby further give, grant, assign, and convey a legally enforceable interest and lien on my case to the clinic against any and all proceeds of any and all causes of action, settlements, judgments, or verdicts by which I may be paid to or through my attorney, or myself, as the result of the injuries or conditions for which I have been treated by the clinic.

I fully understand that I am directly and fully responsible to the clinic for all bills incurred for services rendered to me and that this agreement is made solely for the clinic’s additional protection and in consideration for the clinic waiting for payment. I further understand that payment for services rendered by the clinic is not contingent on any settlement, judgment, or verdict for which I may eventually recover. I am personally responsible for my bills, regardless of the outcome of any legal claim or case.

I fully understand if my attorney(s) does/do not protect the clinic’s interest, the clinic may require me to make payments on a current basis. The clinic may also bring a cause of action against my attorney(s) for failing to honor this binding and irrevocable agreement between me and the clinic.

I further understand and agree that the clinic is not responsible for paying any of my attorneys fees and the clinic does not agree to pay my attorney(s) any attorneys fees for honoring this agreement between me and the clinic.

“ I HAVE READ AND FULLY UNDERSTAND THIS DOCUMENT, AND I AM VOLUNTARILY SIGNING THIS DOCUMENT. I AM DIRECTING MY ATTORNEY(S) TO PROTECT THE CLINIC’S INTEREST AT THE TIME OF SETTLEMENT, AND I AM ASSIGNING AND CONVEYING CERTAIN LEGAL RIGHTS OVER TO THE CLINIC. I ALSO KNOW THAT I MAY NOT REVOKE THIS AGREEMENT AT ANY TIME WITHOUT PRIOR WRITTEN AUTHORIZATION FROM THE CLINIC. I UNDERSTAND THAT, AMONG OTHER THINGS, THIS IS A BINDING AND ENFORCEABLE CONTRACT, ASSIGNMENT, CONVEYANCE, AND LIEN.”