Step 1 of 4
Consent for treatment
When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective.
Chiropractic has one primary goal: It important that each patient understand both the objective and the method that will be used to attain it.
If during the course of chiropractic spinal examination, we encounter non-chiropractic or unusual findings we will advise you to seek the service of a health care provider who specializes in that area. We do not offer advice regarding treatment prescribed by others.
OUR ONLY PRACTICE OBJECTIVE is to eliminate the major interferences to the expression of the body’s health potential. Our only method is the chiropractic adjustment to correct subluxation.
PATIENT FINANCIAL AGREEMENT
1. INDIVIDUAL'S FINANCIAL RESPONSIBILITY
I understand that I am financially responsible for my health insurance deductible, coinsurance, or non- covered service. Co-payments are due at time of service. fI my plan requires a referral, I must obtain it prior to my visit. nI the event that my health plan determines aservice ot be "not payable", Iwil be responsible for the complete charge and agree to pay the costs of al services provided. fI the health plan information provided si not accurate, Iunderstand that Iam liable for al charges for services rendered. Iagree to notify this practitioner immediately whenever Ihave changes ni my health condition or health plan coverage in the future.
2. INSURANCE AUTHORIZATION FOR ASSIGNMENT OF BENEFITS
I hereby authorize and direct payment of my medical benefits to the providers Rivulet Chiropractic and Dr. Christina Alba on my behalf for any services furnished to me by the providers.
3. AUTHORIZATION TO RELEASE RECORDS FOR CLAIM PAYMENT
I hereby authorize Rivulet Chiropractic and Dr. Christina Alba to release to my insurer, governmental agencies, or any other entity financially responsible for my medical care, al information, including diagnosis and the records of any treatment or examination rendered to me needed to substantiate payment for such medical services as well as information required for precertification or authorization.
SCHEDULING APPOINTMENTS
CLINICAL INFORMATION
FINANCIAL POLICIES
YOUR BEST CONTACT INFORMATION
Rivulet Chiropractic, HIPAA Privacy Authorization Form
Authorization for Use or Disclosure of Protected Health Information
(required by the Health Insurance Portability and Accountability Act – 45 CFR Parts 160 and 164)
This authorization affects your rights regarding the privacy of your personal healthcare information.
Please read it carefully before signing.
I understand that my treatment, payment, enrollment or eligibility for benefits will not be affected by my signing or not signing this release.
PLEASE SELECT OPTION A (or) B
I authorize Rivulet Chiropractic or it's Business Associates to release all information to the following family member or friends.
This authorization shall be in force until properly revoked by me at which time this authorization expires.
To revoke my authorization, I must submit a Revocation of Authorization Notice to Rivulet Chiropractic, Attn: Medical Records Manager.
This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct or as permitted by law. Rivulet Chiropractic and its employees, officers and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.
I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
I understand that information used or disclosed according to this authorization may be disclosed by the recipient and may no longer be protected by HIPAA, federal or state law.
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