Cedar Chiropractic & Sports, 77 West Main St. Hopkinton MA
PLEASE INDICATE ON THE DIAGRAM THE AREA OF DISCOMFORT:
REVIEW OF SYSTEMS – Below is a list of symptoms that may be seem unrelated to the purpose of your appointment. However, these questions must be answered carefully as the problems can affect your overall course of care.
Constitutional:
Eyes / Vision:
Ears, Nose and Throat:
Respiration:
Cardiovascular:
Gastrointestinal:
Female:
Male:
Endocrine:
Skin:
Nervous System:
Psychologic:
Allergy:
Hematologic:
Previous Care for Same Condition:
Previous Chiropractic Care:
Current Medication (s):
List ANY / ALL medications you are CURRENTLY taking. Be Specific.
Childhood Illness (es): LIST all health conditions. SELECT all CURRENT conditions.
Adult Illness(es): LIST all health conditions. SELECT all CURRENT conditions
Surgery (ies): LISTall Surgical Procedures. Write the DATE of the Procedure immediately afterward.
Injury (ies): Mark or Listall Injuries. Write the DATE of the Injury immediately afterward.
Family History: Mark all that apply below. List any specific conditions past or present after has / had:
Social History:
Insurance Information:
Who Is Responsible For Your Bill? YOU and … (mark appropriate box(es))
Dr. Binh Nguyen feels that it is very important we coordinate with your doctor(s) and keep them up to date on your treatment and progress here at our office. Please fill in any and all information.
I give authorization to Cedar Chiropractic & Sports P.C. to release my health care information to the above doctors.
DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
Procedure Request and Authorization to Release Medical Records
Please send copies of my medical records including but not limited to diagnostic reports to Cedar Chiropractic & Sports P.C.
DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
I understand there is a no show / no call policy. I will be billed and be responsible for the $45.00 fee.
We are very concerned with protecting your privacy, especially in matters that concern your personal health information. In accordance with, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), we are required to supply you with a copy of our Patient Bill of Rights for Protected Health Information. We encourage you to read this document carefully, for it outlines the use and limitations of the disclosure of your health information and your rights as a patient. If you ever have any questions or concerns regarding the use or dissemination of your personal health information, we would be happy to address the
By signing, you grant authorization to Cedar Chiropractic & Sports P.C., and all its licensed physicians, to perform diagnostic testing and render Chiropractic care and treatment to yourself or said minor (as the parent or authorized legal guardian); you agree to and give consent to operate under those protocols as outlined. WE RESERVE THE RIGHT TO: change our privacy practices and you have the right to request that we do not disclose your health information to specific individuals, companies or organizations. You may also revoke your consent at any time, however this must be done in writing. By signing this consent, you authorize us to use telephone, text, mail or e-mail, as remainder for appointments. You may also revoke this authorization in writing.
WE ask that you sign this form as acknowledgement that our: AOB/DOP, FINANCIAL, APPOINTMENT POLICIES, CONSENT AGREEMENT AND BILL OF RIGHTS ACKNOWLEDGEMENT, were explained to you, that you understand it, and you accept full responsibility.
THIS NOTICE DESCRIBES HOW CHIROPRACTIC AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
III. A. Uses and Disclosur
Here are some examples of how we might have to use or disclose your health care information:
Your chiropractor or a staff member may have to disclose your health information including all of your clinical records to another health care provider or a hospital if it is necessary to refer you to them for diagnosis, assessment, or treatment of your health condition,
Our insurance and billing staff may have to disclose your examination and treatment records and your billing records to another party, such as an insurance carrier, an HMO, a PPO, or your employer, if they are potentially responsible for the payment of your service
Your chiropractor and members of the staff may need to use our health information, examination and treatment records and your billing records for quality control purposes or for other administrative purposes to efficiently run our practice.
Your chiropractor and members of the practice staff may need to use your name, address, phone number, and your clinical records to contact you to provide appointment reminders, information about treatment alternatives, or other health related information that may be of interest to you. If you are not home to receive an appointment reminder, a message will be left on your answering machine. If you prefer, a text will be sent to your phone as an alternative.
You have the right to refuse to give us authorization to contact you to provide appointment reminders, information about treatment alternatives, or other health related information. If you do not give us authorization, it will not affect the treatment we provide to you or the methods we use to obtain reimbursement for your care.
You may inspect or copy the information that we use to contact you to provide appointment reminders, information about treatment alternatives, or other health related information at any time.
B. Our Privacy Pledge
We have an always will respect your privacy. Other than the uses and disclosures we described above, we will not sell or provide any of your health information to any outside marketing organization.
C.Permitted uses and disclosures without your consent or authorization
Under federal law, we are also permitted or required to use or disclose your health information without your consent or authorization in these following circumstance
We are permitted to use or disclose our health information if we are providing health care services to you based on the orders of another health care provider.
We are permitted to use or disclose your health information if we provide health care services to you as an inmate.
We are permitted to use or disclose your health information if we provide health care services to you in an emergency.
We are permitted to use or disclose your health information if we are required by law to treat you and we are unable to obtain your consent after attempting to do so.
We are permitted to use or disclose your health information if there are substantial barriers to communicating with you, but in our professional judgment we believe that you intend for us to provide care.
Other than the circumstances described in the preceding five examples and under the Uses and Disclosures section above, any other use or disclosure of your health information will only be made with your written authorization.
D.Your right to revoke your authorization
You may revoke your authorization to us at any time; however, your revocation must be in writing. There are two circumstances under which we will not be able to honor your revocation request:
If we have already released your health information before we receive your request to revoke your authorization.
If you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they decide to contest any of your claims.
If you wish to revoke your authorization please write to us at: Cedar Chiropractic & Sports P.C. 77 West Main St. Suite 203B Hopkinton, MA 01748
E. Your right to limit uses or disclosures
If there are health care providers, hospitals, employers, insurers or other individuals or organizations to whom you do not want us to disclose your health information, please let us know, in writing, what individuals or organizations to whom you do not want us to disclose your health care information. We are not required to agree to your restrictions. However, if we agree with your restrictions, the restriction is binding on us. If we do not agree to your restrictions, you may drop your request or you are free to seek care from another health care provider.
F. Your right to receive confidential communication regarding your health information
We normally provide information about your health to you in person at the time you receive chiropractic services from us. We may also mail you information regarding our health or about the status of your account. We will do our best to accommodate any reasonable request if you would like to receive information about your health or the services that we provide at a place other than your home or, if you would like the information in a different form. To help us respond to your needs, please make any request in writing.
G. Your right to inspect and copy your health information
You have the right to inspect and/or copy your health information for seven years from the date that the record was created or as long as the information remains in our files. We require your request to inspect and/or copy your health information to be in writing.
H. Your right to amend your health information
You have the right to request that we amend your health information for seven years from the date that the record was created or as long as the information remains in our files. We require your request to amend your records to be in writing and for you to give us a reason to support the change you are requesting us to make.
We will provide the first accounting within any 12-month period without charge. There is a fee for any additional requests during the next 12 months. When you make your request we will tell you the amount of the fee and you will have the opportunity to withdraw or modify your request.
J. Our duties We are required by law to maintain the privacy of your health information.
We are also required to provide you with this notice of our legal duties and our privacy practices with respect to your health information. We must abide by the terms of this notice while it is in effect. However, we reserve the right to change the terms of our privacy notices. If we make a change to the terms of our privacy agreement we will notify you in writing when you come in for treatment or by mail. If we make a change in our privacy terms the change will pally for all of your health information in our files.
K. Re-disclosure
Information that we use or disclose may be subject to re-disclosure by the person to whom we provide the information and may no longer by protected by the federal privacy roles.
L. Your right to complain
You may complain to us or to the Secretary for Health and Human Services if you feel that we have violated your privacy rights. We respect your right to file a complaint and will not take any action against you if you file a complaint. While you may make an oral complaint at any time, written comments should be addressed to: Dept. of Health and Human Services 200 Independence Avenue, SW Washington, DC 20201 Tel: (877) 696-6775
We strive to provide the highest quality health care, all the while maintaining afford ability for you, the patient. We understand that even with insurance, most patients will experience at least some out of pocket expense.
Participating Insurance
Our office will accept your insurance on assignment and do participate as preferred providers for many insurance plans. However, it must be fully understood that your insurance policy is a contract between you and your insurance company. Our office will not enter into a dispute with your insurance company over policy limitations or insurance policy issue. This is your responsibility and obligation.All charges incurred are your responsibility. If you have a question or concern with your reimbursement, you will need to contact your employer or insurance company. Our office will file your claims for you and assist you in every way possible to ensure benefit recovery.We cannot be certain if your insurance covers chiropractic care, although most policies do provide coverage. The amount they pay varies from one policy to another. We will call to verify benefits on your insurance; however, the benefits quoted to us by your insurance company are not a guarantee of payment.It is our policy and agreed that any services rendered are charged to you directly and you are responsible for payment of any non-covered services, deductibles or co-pays.
Non-Participating Insurances
We will gladly bill your Insurance for you, and will call to determine your chiropractic benefits. Payment is due at the time of service for all deductibles, co-pays, and non-covered therapies unless arrangements are with the office staff.
Patients without Insurance
We request that 100% of the examination and treatment be paid at the time of the visit, unless other arrangements have been made. To qualify for our Time of Service Reduction in fees you must pay on the day the service was performed. We are happy to accept cash, check, Master Card, Visa, Discover or American Express.No insurance will be billed.
Medicare
Our office accepts assignment from Medicare. Reimbursement is sent directly to our office in payment for chiropractic services that Medicare will cover. Medicare will ONLY cover manipulation of the spine. Medicare pays 80%of the allowable fee once the deductible has been met. You are required to pay the deductible and the remaining fees for services Medicare does not reimburse.These non-covered services include, but are not limited to, x-rays, examinations, therapies, orthotics, supports, and/or nutritional supplements.Medicare patients are fully responsible for charges of non-covered services.Secondary insurance may or may not pay for these non-covered services. Our office completes and files the forms for Medicare at no charge.
Secondary Insurance
Please inform us of any secondary insurance you may have. We will file and collect from your secondary insurance for services covered by the secondary payer.
Flex Plans/Medical Savings Accounts
Please inform us if you have a medical savings account, or a 'flex spending plan'.We will be happy to provide you with a statement of your charges for reimbursement.
Health Saving Accounts(HSA)/High Deductible Health Plan
Please inform us if you have an H.S.A. As Chiropractic is a qualified expense and this can be paid through your H.S.A. and billed to your high deductible health plan.Please read the following office policy regarding assignments:
Personal Injury (PI)or Automobile Accidents
Please present your auto insurance card, your health insurance card, and inform usif you have retained an attorney. If you need an attorney we will refer you to an attorney.
There are four options available to the PI patient:
Although you are ultimately responsible for your bill, we will wait for settlement of your claim for up to 6(six)months after your care is completed. Once the claim is settled or if you suspend or terminate care, any fees for services are due immediately
I have read and understand this financial policy. I realize that I am responsible for all charges incurred by meat Cedar Chiropractic & Sports PC.
WE ask that you sign this form as acknowledgement of our financial policy agreement:Cedar Chiropractic & Sports PC Financial Policy, were explained to you, that you understand it, and you accept full responsibility.
I have received the information about my condition and proposed chiropractic treatment program as well as alternative courses of care, the benefits, the risks, and the side effects of the treatment and the consequences of not having the proposed treatment. I understand and am informed that, as in all health care, in the practice of chiropractic there are some rare risks to treatment, including but not limited to muscle soreness, muscle aches, muscle bruising, muscle strains and sprains, fractures, dislocations, disc injuries, and strokes. I do not expect the healthcare provider to be able to anticipate or explain all risks and complications. I wish to rely on the provider to exercise judgment during the course of the treatments which they feel at the time, based upon the facts then known, is in my best interests. My chiropractor has responded to all of my requests for information about the proposed treatment. I have read, or have had read to me, the above consent. I have also had the opportunity to ask questions about its content. By signing below, I consent to chiropractic treatment. I also consent that I have authority and responsibility to authorize treatment for my child if such condition is applicable.
DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
We have implemented a policy which enables you to maintain your credit card information securely on file with Cedar Chiropractic & Sports, PC. In providing us with your credit card information, you are giving Cedar Chiropractic & Sports, PC permission to automatically charge your credit card on file for your (or any other patient(s) you have listed on this form) co-pay/s, outstanding balance/s, service/s, missed appointment/s without cancellation and /or product/s)
Co-pays: Co-pays are due at time of the office visit.
Outstanding Balance: If your insurance provider has paid their portion of your bill (or any other patient(s) you have listed on this form) and there is still an outstanding balance owned, Cedar Chiropractic &Sports , PC will notify you via phone and/or mail. If by the final billing notice from Cedar Chiropractic & Sports, PC, we do not receive a response from you or your payment in full, at that time, any balance owed will be charged to your credit card. A copy of the charge will be mailed to you. This in no way compromises your ability to dispute a charge or question your insurance company’s determination of payment.
Service and Products: missed appointment/s without cancellation and product fee are due at time of office visit.
This card will only be authorized for the use of the credit card holder or any person(s) listed below by the credit card holder. This agreement will expire on the expiration date listed below. The card holder may also revoke this consent at any time in writing.
Please fill out information below for any other person/s you authorize this credit card for:
DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
Your information will be encrypted.