New Patient Form 2022

Client Information

Insurance

Emergency Contact

Who do you authorize us to release your medical records to ( mom, dad, spouse, boyfriend, etc.):

Primary Care Physician

Case History

Lifestyle

Identify and/or list medical concerns

Family History

WELCOME TO OUR OFFICE

In compliance with Federal and State Consumer Protection and Informed Consent Laws, we present the following basic outline of usual and customary procedure and fees.

Examination/Evaluation (If Necessary) $45-$140

Graston (If Necessary) $35

Each Therapy (If Necessary) $10-$50

Spinal Adjustment (If Necessary) $38-$58

Kinetic Activity (If Necessary) $38

IF NO INSURANCE: Payment is due when the service is rendered. We gladly accept cash, check, Debit Card, Visa, MasterCard, or Discover. No more than three payment installments shall be allowed if not on auto-debit plan.

INSURANCE: Please pay your co-insurance of your charges on your first visit. After we receive payment from your insurance company, we will bill you for any balance due. Any procedures not covered by your insurance will have to be paid by you at the time of service. If you fail to keep your scheduled appointments or if you discontinue care for any reason other than discharge by the doctor the bill is due and payable in full immediately, regardless of any insurance claims submitted.

MEDICARE/MEDICAID: Medicare insurance covers adjustments by the chiropractor. Medicaid covers chiropractic adjustments along with a $1 co-pay per visit (when applicable).

Advance Beneficiary Notice of Non-coverage: Note Medicare / Medicaid do not pay for everything, even some care that you or your health-care provider have good reason to think you need. Medicare and Medicaid typically only pay for spinal adjustments in a chiropractic office; therefore if your insurance does not pay for the care, you may have to pay. This notice gives our opinion, and is not an official Medicare/Medicaid decision. If you have questions on this notice you may call Medicare 1-800-633-4227 or your Medicaid carrier.

INTEREST CHARGES: Interest will be charged to all delinquent accounts. Any cost to collect said delinquent accounts will be your responsibility. Campbell Chiropractic Clinic, P.C. reserves the right to charge an additional fee for collection of delinquent accounts.

ASSIGNMENT OF RIGHT TO PAYMENT/LIEN AGAINST BENEFITS: I hereby authorize Campbell Chiropractic Clinic, P.C. to file my claim. I assign to them my right to receive any and all payments or recoveries from any insurance company, attorney, or third party for professional services rendered by Campbell Chiropractic Clinic, P.C. I convey a lien against any funds and authorize and direct any third party to withhold sum from any benefits, judgments, verdict, settlements, or recoveries, and to adequately protect and to make payment for these services directly to Campbell Chiropractic Clinic, P.C. pursuant to this assignment and lien.

ASSIGNMENT OF CAUSE OF ACTION: In the event that any insurance company or other third party obligated to make payment to me or to Campbell Chiropractic Clinic, P.C. for the charges made for services, refuses to make such payment upon demand, I hereby assign, transfer and convey to Campbell Chiropractic Clinic, P.C. any and all cause of action that might exist in my favor against any such company or person. I authorize Campbell Chiropractic Clinic, P.C., to prosecute said action either in my name or their name to collect fees due for care rendered and legal expenses and to resolve said claims as they see fit. In the event that it becomes necessary to retain an attorney, I agree that I am responsible for all court costs and attorney fees.

AUTHORIZATION TO PROCESS DRAFTS: I agree that Campbell Chiropractic Clinic, P.C. shall be appointed as my agent to endorse drafts or to sign my name on any checks for payment of my bill for medical services rendered.

VENUE: I agree that all charges are payable and collectable in Union County, South Dakota and that all provisions of this contract are to be performed in Union County. The invalidity or unenforceability of any provision hereof shall in no way affect the validity or enforceability of any other provision.

Signing below indicates that I understand this notice.

You may request a copy of this notice. This is NOT a consumer credit transaction

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

Section A: Patient Giving Consent:

Section B: Please read the following statements carefully:

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. We encourage you to read it carefully and completely before signing this Consent. A copy of our Notice is available at the front desk or you can click on the tab under patient paperwork.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes that may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice at any time by contacting:

Contact: Robin L. Bobier

Telephone: 605-232-3833 Fax: 605-232-5255

Address: 558 River Drive, P.O. Box 1427 North Sioux City, SD 57049

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation and that we may decline to treat you or to continue treating you if you revoke this Consent. I authorize Campbell Chiropractic Clinic, P.C. to contact me on my health condition to promote health services at Campbell Chiropractic Clinic, P.C.

I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out our treatment, payment activities, and health care operations.

INFORMED CONSENT FOR CHIROPRACTIC TREATMENTS AND CARE

I hereby request and consent to the performance of chiropractic adjustments, nutritional testing and counseling, blood testing, and other chiropractic procedures, including various modes of physical therapy and diagnostic x-rays, on me (or on the printed named below, for whom I am legally responsible) by the doctors of chiropractic, Dr. Adam Bobier or Dr. Taylor Lambert, who now or in the future may treat me. I have had an opportunity to discuss with the doctor of chiropractic named 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 chiropractic there are some risks to treatment including, but not limited to fractures, disk injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications. And I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known, are in my best interests.

I have read or have had read to me, the above consent. I have also had the opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and from any future condition(s) for which I seek treatment.

I authorize payment of medical benefits to Campbell Chiropractic Clinic, P.C. for any and all services provided.

You are entitled to a copy of this consent after you sign it. You may obtain a copy by request.