CHIROPRACTIC REGISTRATION FORM

**Please provide a copy of your insurance card for verification **

Emergency Contact Information

NOTICE TO OUR NEW PATIENTS:

It is the policy of this office for patients to make payment (cash payments, co-payments, etc.) for services rendered prior to each visit. Other payment arrangements (ie. payment plans, etc) must be specifically discussed and/or approved by this office prior to treatment initiation. Deductible payments will be billed on receipt of insurance EOB.

ASSIGNMENT TO PAY BENEFITS TO PHYSICIAN:

I hereby certify that I (or my dependent, parent, or guardian) have insurance coverage as stated above. I assign payments and/or medical benefits, if any, otherwise payable to me for services rendered from this office, directly to Marion Chiropractic Clinic. I understand I am personally and financially responsible for payment in full for all charges and expenses related to my treatment not covered by this assignment, regardless of insurance coverage. In addition, I hereby authorize this office to release all information necessary to communicate with personal physicians and other providers, as well as payors to secure payment of benefits. I acknowledge this assignment and authorize the use of the signature below for all insurance submissions.

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.

What is (are) your present complaint(s) or reason for your visit? When did your symptoms appear?

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.

**To the best of my knowledge, the questions on these forms have been answered accurately. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform Marion Chiropractic Clinic of any changes in my personal information, insurance changes, or medical status in a timely manner.

Informed Consent to Chiropractic Treatment

The nature of chiropractic treatment: The doctor will use his/her hands or a mechanical device in order to move your joints. You may feel a “click” or “pop”, such as the noise when a knuckle is “cracked”. You may feel movement of the joint.

Ancillary treatments: Various ancillary procedures, such as hot or cold packs, electric muscle stimulation, therapeutic ultrasound, traction, or exercise/rehab may also be used.

Possible Risks: As with any health care procedure, complications are possible following a chiropractic manipulation. Complications could include fractures, muscular strain, ligamentous sprain, dislocations of joints, or injury to intervertebral discs, nerves or spinal cord. Some types of manipulation of the neck have been associated with injuries to the arteries of the neck leading to cerebrovascular injury or stroke. A minority of patients may notice stiffness or soreness after the first few days of treatment. The ancillary procedures could also produce skin irritation, burns or minor complications.

Probability of risks occurring: The risks of complications due to chiropractic treatment have been described as “rare”, about as often as complications are seen from the taking of a single aspirin tablet. Fractures are rare occurrences and generally result from underlying weakness of the bone, which we check for during the history and exam and other testing. The risk of cerebrovascular injury or stroke, has been estimated at one in one million to one in twenty million, and can be even further reduced by screening procedures during examination. The probability of adverse reaction due to ancillary procedures is also considered “rare”.

Other treatment options which could be considered may include the following:

• Over-the-counter analgesics. The risks of these medications include irritation to stomach, liver and kidneys, and other side effects in a significant number of cases.
• Medical care, typically anti-inflammatory drugs, tranquilizers, and analgesics. Risks of these drugs include a multitude of undesirable side effects and patient dependence in a significant number of cases.
• Hospitalization in conjunction with medical care adds risk of exposure to virulent communicable disease in a significant number of cases.
• Surgery in conjunction with medical care adds the risks of adverse reaction to anesthesia, as well as an extended convalescent period in a significant number of cases.

Risks of remaining untreated: Delay of treatment allows formation of adhesions, scar tissue and other degenerative changes. These changes can further reduce skeletal mobility, and induce chronic pain cycles, which may complicate treatment making it more difficult and less effective the longer it is postponed. The probability that non-treatment will complicate the condition is very high.

DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE.

I have read the explanation above of chiropractic treatment. I have had the opportunity to have any questions answered to my satisfaction. I have fully evaluated the risks and benefits of undergoing treatment. By signing below, I have freely decided to undergo the recommended treatment. Having been informed of the risks, I hereby give my full consent to treatment.

Assignment / Claim payment agreement

I understand and agree that health insurance and accident insurance are arrangements between my insurance carrier and me. I am aware that by not paying the amount that I am contracted, I may be subject to dismissal from any current health plan. These payable amounts include, but are not limited to any calendar year deductible, office visit co-pays, and any co-insurance payment.

I hereby certify that I (or my dependent, parent, or guardian) have insurance coverage as reported. I assign payments and/or medical benefits, if any, otherwise payable to me for services rendered from this office, directly to Marion Chiropractic Clinic. In the event that an insurance payment would come directly to my attention for services rendered and outstanding at this office, I agree to return said payment to Marion Chiropractic Clinic in an expedited and timely manner, or I may be subject to legal action.

Furthermore, I understand that Marion Chiropractic Clinic will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be directly paid to this office will be credited to my account on receipt. However, I understand and agree that I am personally and financially responsible for payment in full for all charges and expenses related to my treatment not covered by this assignment, regardless of insurance coverage.

I also understand that if I suspend of terminate my treatment, any fees for professional services rendered to me will be immediately due and payable. I also understand that there could be an interest charge applied monthly on any outstanding balance.

In addition, I hereby authorize this office to release all pertinent information necessary to communicate with personal physicians and other providers, as well as payors, to secure payment of benefits, expedite the payment process, or whenever the insurance company may require the information to make a determination of benefits.

I acknowledge this assignment and authorize the use of the signature below for all insurance submissions.

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.

NOTICE OF PRIVACY PRACTICE

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW THIS CAREFULLY.

Our commitment at Marion Chiropractic Clinic is to serve our patients with professionalism and high quality care, being sure at all times to protect the privacy and security of all protected health information.

During the course of serving your interests, it may be necessary to share information with other healthcare providers or business associates as allowed by law.

We at Marion Chiropractic Clinic are committed to obeying all Federal, State, and Local laws and regulations regarding privacy practices. If any uses or disclosures are necessary, information will only be released with the below written authorization of the individual in question. This written authorization may be revoked at any time by the individual, as provided by law.

If you have any questions or comments regarding your protected health information, feel free to contact a member of our staff or the doctor.

AUTHORIZATION TO RELEASE INFORMATION ACCORDING TO HIPAA:

I hereby authorize Marion Chiropractic Clinic LLC, to release any information acquired in the course of my examination and/or treatment in accordance to HIPAA (Health Insurance Portability and Accountability Act) guidelines. I understand this protected patient health information will be utilized for the purpose of relevant treatment, healthcare operations, and co-ordination of care. The release of information will also include but not be limited to the processing of medical claims or information requested by insurance companies and/or other legal representatives after which proper authorization is received at this office. I also understand that a more detailed account of the privacy policies and procedures can be requested prior to signing this form. If there is anyone you do not want to receive your medical information / records, please inform the office. I understand and agree to the release of my health information as stated above, and allowed by law, which is in accordance to HIPAA guidelines.