APPOINTMENTS: When scheduling an appointment, please describe your needs to our staff so an appropriate length of time can be reserved for you. We attempt to schedule appointments to accommodate our patient's needs. We also make every effort to see patients at scheduled appointment times, as we realize your time is valuable. However, sometimes we do fall behind schedule or are called out of the office to attend to emergency cases. Our staff will attempt to notify you by telephone so you can choose to either keep your appointment time or reschedule it.
CANCELLING AN APPOINTMENT: If you cannot keep your appointment, please give us at least 24 hours notice, or as much as possible, as we understand emergencies occur. Additionally, if you will be unavoidably late for your appointment, please call us to let us know. You may contact Port jervis Chiropractic at 845-858-8000 or 845-856-1800. The fax number is 845-858-8006.
FINANCIAL POLICIES: Port Jervis Chiropractic appreciates the confidence you have shown in choosing us to provide your chiropractic care. The service you have elected to participate in implies a financial responsibility on your part. As a courtesy, we will verify your coverage and bill your insurance carrier on your behalf. You are responsible for payment for any deductible and co-payment/co-insurance as determined by your contract with your insurance carrier. If your insurance carrier denies any part of your claim, or if you or Port jervis Chiropractic elect to continue care past your approved period, you will be responsible for your account balance in full. If we do not participate with your insurance, payment in full is expected for services at the time they are rendered, unless other arrangements have been made.
Forms of Payment: Please be advised that Port Jervis Chiropractic accepts payment in the form of checks, money orders, cash and credit cards including Visa, Master card, Discover and American Express. There is a 3% processing fee charged by the Credit card Company. Please be advised that when utilizing a credit card the individual whose name is printed on the card must be present for signature when the card is offered for payment. Any returned check will incur an additional $30.00 fee.
Port Jervis Chiropractic understands at times that families may incur unforeseen hardships. If for any reason you are having financial difficulty, please feel free to discuss your situation with a member of our staff, in confidence. And Port jervis Chiropractic will make payment arrangements with you in order for you to continue with your chiropractic care.
By signing this form, you (the "patient" or "patient guardian", if under eighteen years of age) understand you are ultimately responsible for all charges accumulated and guarantee payment of any and all charges incurred. You hereby authorize Port jervis Chiropractic to release all information necessary to secure payment of benefits, and authorize the use of this signature on all insurance submissions. You further give Port jervis Chiropractic, its' agents and/or employees, permission to discuss your claim with your insurance carrier. You understand bills are due upon presentation and in the event of default in fulfilling the terms of this agreement, you agree to pay, in addition to the amount owing on your account, reasonable attorney's fees incurred in collection of the account.
CONFIDENTIALITY: Confidentiality is primary in patient health care provider relationship. Information regarding your visit to Port jervis Chiropractic will not be released or discussed with anyone without your written consent.
When records are requested by an outside agent, Port Jervis Chiropractic requires a written Release of information before providing the information to the requesting agent.
For our security and right to privacy, all staff has been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures in our office. Port Jervis Chiropractic has taken all precautions that are known by this office to assure your records are not readily available to those who do not need them.
A copy of Port Jervis Chiropractic's Notice of Privacy Practices, which outlines how health information about the patient may be used or discussed is provided to each patient at their first visit. In addition, Port Jervis Chiropractic's Notice of Privacy Practice is displayed in the reception area of Port jervis Chiropractic and additional copies are provided upon request.
By signing below, you (the "patient" or "patient's guardian", if under eighteen years of age) acknowledge receipt of Port jervis Chiropractic's Notice of privacy Practices.
In addition, you (the "patient" or "patient's guardian, if under eighteen years of age) hereby authorize Port jervis Chiropractic to release information as may be necessary for your care and for the completion of treatment claims via mail, electronic, or facsimile transmission. You further acknowledge medical information, while adhering to federal, state and local regulations, will be disclosed to any organization responsible for reimbursement for provision of care/services and you hereby consent to the transfer of information as appropriate. You further release Port jervis Chiropractic from all legal liability that may arise from the release of the information requested.
ACKNOWLEDGE AND CONSENT: By signing below, you (the "patient" or "patient's guardian", if under eighteen years of age) hereby consent to Dr. Joseph J. Spano of Port Jervis Chiropractic to render care, which may include routine diagnostic tests and/or procedures and such other chiropractic procedures as directed by Dr. Joseph I. Spano considered to be necessary. By signing below, you further acknowledge that the practice of chiropractic is not an exact science, and that diagnosis and treatment may involve risks of injury. In addition, you further acknowledge no guarantees have been made to you as the result of examination or treatment of this office. You further understand each patient has the right to consent, or to refuse consent, to the proposed procedure of therapeutic course.
A patient's written consent need only be obtained one time for all subsequent care given the patient in this office.
If you have any questions regarding any information contained in this "Information and Consent Form" please feel free to ask a member of our staff. By signing below, you hereby acknowledge you have read and understand this "Information and Consent Form" and understand its content and significance. You further permit a copy of this "Information and Consent Form" to be used in place of the original. In addition, you hereby acknowledge receipt of a copy of this form.