TERMS OF ACCEPTANCE
When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment.
Adjustment: An adjustment is the specific application of forces to facilitate the body's correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine.
Health: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity.
Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body's innate ability to express its maximum health potential.
We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal examination, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area.
Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body's innate wisdom. Our only method is specific adjusting to correct vertebral subluxations.
CONSENT TO EVALUATE AND TREAT A MINOR
I acknowledge I am the parent or legal guardian and have read and fully understand the above terms of acceptance and hereby grant permission for my child to receive chiropractic care.
ASSIGNMENT AND AUTHORIZATION
I certify that if I and/or my dependent(s) have insurance coverage, I assign directly to Be Well LifeStyle Centers and its affiliates all medical 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 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.
HIPAA Consent
I consent to the use or disclosure of my protected health information by Be Well LifeStyle Centers for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of Be Well LifeStyle Centers. I understand that diagnosis or treatment of me by Be Well LifeStyle Centers may be conditioned upon my consent as evidenced by my signature on this document.
I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice. Be Well LifeStyle Centers is not required to agree to the restrictions that I may request. However, if Be Well LifeStyle Centers agrees to a restriction that I request, the restriction is binding on Be Well LifeStyle Centers.
I have the right to revoke this consent, in writing, at any time, except to the extent that Be Well LifeStyle Centers has taken action in reliance on this consent.
My "protected health information" means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.
I understand I have a right to review Be Well LifeStyle Centers Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Be Well LifeStyle Centers.
Be Well LifeStyle Centers reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice by calling the office and requesting a revised copy.
I agree to assume full responsibility for any and all charges incurred in the care of the above patient. If insurance is filed, payment is subject to insurance company approval. I understand and agree that any amount not covered by insurance is my responsibility. I will make payment arrangements for any balance due.
