Please complete this questionnaire. Your answers will help us determine if our care can help you. If we do not sincerely believe that your condition will respond satisfactorily, we will not accept your case but will work to refer you to the appropriate healthcare provider. If you need help with this form, please ask our staff.
I hereby state the above information to my knowledge is accurate.
Outstanding patient balances will be billed monthly. Should my account become delinquent, I agree to pay collection costs, attorney fees and court costs as permitted by law if such are incurred by my physician at Meier Chiropractic. We will pass along the charge of $20 for any returned checks. If your case is a Personal Injury Case or Workers Comp case and you decide to terminate care against the doctor's advice, the entire balance will immediately become due and payable.
This is the entire financial agreement between Meier Chiropractic and the patient below. I have read this agreement, understand it and agree with its provisions.
I hereby request and consent to the performance of Chiropractic adjustments and any other procedures, including examination tests, diagnostic x-rays and adjustment necessary to treat or diagnose my condition. Furthermore, I consent to treatment by any chiropractor that may be working for, associated with or serving as backup for my regular chiropractor named below.
I understand that, as with any health care procedure, there are certain risks involved. Some of the risks or complications which may occur during a chiropractic adjustment include, but not limited to; fractures, disc injuries, muscle strains, and costovertebral strains and /or separations. In a small percentage of the population there have been injuries to the arteries in the neck resulting in or contributing to stroke. In some of these incidents the manipulative procedures were performed by untrained people such as massage therapists, beauticians, and even medical doctors not adequately trained in the science of chiropractic.
By signing below I state I have weighed the risk involved in undergoing treatment and have myself decided that it is in my interest to undergo the chiropractic treatment recommended. I hereby give consent to the treatment. I intend this consent form to cover the entire course of treatment for my present condition and for any other future conditions for which I seek treatment.
Treating Doctor: Jeff Meier, D.C; Kim Meier, D.C; Donnie Smith, D.C; Tilene Figeroa, D.C
We here at Meier Family Chiropractic take your care very serious and want what is best for you at all times. Under the Health Insurance Portability and Accountability Act (HIPAA), your health care provider may share your information face-to-face, over the phone, or in writing.
A health-care provider may share relevant information if:
If you would like us to share information (i.e. appointment dates/times, current balances, etc.) please list the person's name and we will be happy to abide by this. I authorize Meier Family Chiropractic to release my healthcare information to the following:
*By signing this form, I am indicating that I have been provided a copy of Meier Chiropractic's Notice of Privacy Practices related to health information. I understand that the Notice is subject to change, and I may obtain a current notice by contacting Meier Chiropractic. The doctors and staff of Meier Family Chiropractic will follow the above directions until notified in writing of a change.
*Appointment reminders and private health information will be communicated to you only in the manners in which you have given specific written authorization and you have the option to opt out of any of those methods at any time by notifying our office. Email and standard SMS/text messaging are not confidential methods of communication and may be insecure.
I give permission to contact me, relative to appointment reminders only, by the following methods:
Your information will be encrypted.