Patient Forms
New Patients
Please fill out the information below to the best of your capability. The more details we have about you and your lifestyle, history, and surroundings, the better we can understand how to treat you. Get in touch with us by calling our office at 512-268-2768.
We are looking forward to you experiencing the magic of Benevida!
New Patient (Medicare)
Patient Information
Initial Problem Record
Medical History and Present Medical Condition Questionnaire
Additional Health and Lifestyle Questions
Trauma History
Financial Agreement
This office is committed to providing you with the best possible medical care, and we are available to discuss our professional
fees with you at any time. Your clear understanding of our financial policy is important to our professional relationship.
WE ACCEPT CASH, LOCAL CHECKS, CREDIT CARDS (VISA, MASTERCARD, DISCOVER, AMEX), AND CARECREDIT
PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED, UNLESS PRIOR ARRANGEMENTS HAVE BEEN MADE INSURANCE IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANY
We do not accept assignment for Medicare, however, we will charge our cash prices and electronically submit an insurance claim for you – as a courtesy to you. During your chiropractic visit, you will receive extra care in addition to your adjustment.
We perform several procedure codes; however Medicare covers the adjustment code ONLY. Typically you will be mailed a partial refund, between $24-$26 for your adjustment along with a letter explaining your benefits.
We accept assignment for Workers’ Compensation and most Medical Insurances. We will electronically bill your insurance company for payment, but we are not a party to your insurance contract. Again, we will bill your insurance company as a courtesy to you. You will still be responsible for deductibles, and any and all services, not covered by your insurance company.
PRE-PAYMENTS: Patient is entitled to a reimbursement for services not rendered, however all used sessions will be billed at the non-discounted rate and refunded remaining balance.
MISSED APPOINTMENTS
As a courtesy to your fellow patients and to our staff, we require at least 24 hours notice of cancellation of any appointment.
Unless your appointment is cancelled at least 24 hours in advance we will charge you at the rate of a normal office visit (insurance does not cover missed appointments.) Please help us serve you better by keeping your scheduled appointments.
PATIENT LIENS
I fully understand that I am directly responsible to Bene Vida Health + Wellness Center for all medical bills submitted by them for services rendered to me. Further, this agreement is made solely for this facility and it’s practices, additional protection and in consideration of awaiting payment.
Should any of my account balances be turned over for collections, I agree that I will be responsible for all attorney fees, court costs, collection fees, certified mailing fees and interest that is accrued on my balance until paid in full at 18% per anum.
Assignment of Benefits
ASSIGNMENT OF BENEFITS and RELEASE OF AUTHORIZATION
I hereby authorize my insurance company to make payments to Benevida Chiropractic for chiropractic or massage services rendered to me or my dependents, if applicable. Should my insurance carrier deny Benevida Chiropractic payment, I understand that I am financially responsible for all charges. I authorize Benevida Chiropractic to release any and all of my records to my insurer, or any third party payer, legally responsible for the payment of chiropractic or massage. I certify that the information provided or to be provided by me is correct and complete to the best of my knowledge. It is my responsibility to update any and all personal, insurance, and health information. I agree that a photocopy of this assignment shall serve in lieu of the original.
HIPAA Notice
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.
In the course of your care as a patient at Well Connected Chiropractic we may use or disclose personal and health related information about you in the following ways;
1. Your protected health information, including your clinical records, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assessment or treatment.
2. Your health care records as well as your billing records may be disclosed to another party, such as an insurance carrier, agent, adjuster, HMO, PPO, or your employer, if they maybe responsible for the payment of services provided to you.
3. Your name, address, phone number, and your health care records may be used by our office only to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information.
You have a right to request restrictions on our use of your protected health information for treatment, payment and operations purposes. Such requests are not automatic and require the notice to this office.
Your name, address, telephone number, e-mail address and health records may be used to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information that maybe of interest to you. If you are not home to receive an appointment reminder or other related information, a message may be left on your answering machine or with a person in your household.
You have a right to confidential communications and to request restrictions relative to such contacts. You also have the right to be contacted by alternative means or at alternative locations.
We are permitted and may be required to use or disclose your health information without your authorization in these following circumstances:
1. If we provide health care services to you in an emergency.
2. If we are required by law to provide care to you and we are unable obtain your consent after attempting to do so.
3. If there are substantial barriers to communicating with you, but in our professional judgment we believe that you intend for us to provide care.
4. If we are ordered by the courts or another appropriate agency.
You have the right to receive an accounting of any such disclosures made by this office. Any use or disclosure of your protected health information, other than as outlined above, will only be made upon your written authorization. If you provide an authorization for release of information you have the right to revoke that authorization at a later date. Information that we use or disclose based on this privacy notice may be subject to re-disclosure by the person to whom we provide the information and may no longer be protected by the federal privacy rules. We normally provide information about your health to you in person at the time you receive chiropractic care from us. We may also mail information to you regarding your health care or about the status of your account. If you would like to receive this information at an address other than your home or if you would like the information in a specific form please advise us in writing.
You have the right to inspect and/or copy your health information for as long as the information remains in our files. In addition you have the right to request an amendment to your health information.
Requests to inspect, copy or amend your health related information should be provided to us in writing. We are required by state and federal law to maintain the privacy of your patient file and the health protected health information therein.
We are also required to provide you with this notice of our privacy practices with respect to your health information.
We are further required by law to abide by the terms of this notice while it is in effect. We reserve the right to alter or amend the terms of this privacy notice. If changes are made to our privacy notice we will notify you in writing as soon as possible following the changes. Any change in our privacy notice will apply for all your health information in our files. If you have a complaint regarding our privacy notice, our privacy practices or any aspect of our privacy activities you should direct your complaint to: If you would like further information about our privacy policies and practices please contact: You also have the right to lodge a complaint with the Secretary of the Department of Health and Human Services. If you choose to lodge a complaint with this office or with the Secretary your care will continue and you will not be disadvantaged by this office or our staff in any manner whatsoever.
This notice is effective as of April 2003, and any alterations or amendments made hereto will expire seven years after the date upon which the record was created.
My initials acknowledge that I have received a copy of this notice.
Chiropractic Informed Consent
The nature of the chiropractic manipulation: I will use my hands or instrument to move joints of
your body. This may result in an audible “pop” or “click”.
The material risk inherent in an adjustment: As with any health care procedure, there are certain
complications that may arise during a chiropractic manipulation. This may include strains, dislocations,
fractures, disc injuries, and strokes. This list in not all conclusive.
The probability of those risks: Fractures are rare and can result from an underlying weakness in
the bones. The other complications are considered rare. One source states that stroke is a possible
occurrence in 1/1,000,000 cases or higher. We employ tests during our examination to identify if you
may be susceptible to that kind of injury.
Ancillary treatment recommended: Manipulations, cervical rehabilitation, cervical traction, lumbar
traction, lumbar rehabilitation, manual therapy, electrical modalities, physical modalities, ice therapy,
and heat therapy.
Other treatment options for your condition may include: Medical care with prescription drugs,
self-management with over-the-counter medication, rest and/or surgery. There is material risk
inherent in each of these options, including but not limited to, addiction to medications, side effects of
medication, improper self-dosage, and surgical risk, including complications from the procedure and
the anesthesia.
I have read or have had read to me the above explanation of the chiropractic adjustment and the
related treatment. I have discussed with the doctor and have had my questions answered to my
satisfaction. By signing below, I state that I have weighted the risks involved in undergoing treatment
and I have decided that it was in my best interest to undergo the treatment recommended. Having
been informed of the risks, I hereby give my consent to treatment.
About Medicare
ABOUT MEDICARE COVERAGE
The government’s Medicare program only pays Doctors of Chiropractic (DCs) for limited services. If your needed Chiropractic Adjustment (manipulation treatment) meets Medicare’s rules, they will usually pay for it. There are three categories of Medicare services: 1.) non-covered 2.) always covered, and 3.) perhaps covered.
NON-COVERED
According to existing Medicare law, most of the available services in our office are NON-COVERED. Hopefully, the U.S. Congress will change that someday and treat Doctors of Chiropractic like all other doctors. Until then:
Examples of Non-Covered Services
All Services Other than Chiropractic Adjustments:
· Office Visits- to evaluate and manage, re-evaluate, advise, or
counsel.
· Physiotherapy- such as massage, traction, electrical
stimulation, neuromuscular re-education, etc.
· X-rays, Laboratory, Supplies, Vitamins, etc.
Various Chiropractic Adjustments:
· Adjustment on an area other than the spine- (to the shoulder, arm, leg, etc.)
· Maintenance Care- you are stable and not making any more improvement.
· Wellness Care- to promote better health.
NON-Covered items will appear on your insurance claim form.
They will show as a Medicare NON-Covered service like this: “72010-GY”. The “72010” code is for an x-ray. The “–GY” code means that it is not-covered, allowing your service to go through the Medicare system. After denial by Medicare, it can then go onto your other insurance. If you have Medigap insurance (also known as Medicare Secondary or Supplemental insurance), they will pay according to the terms of your contract.
ALWAYS COVERED
A Typical example of a Medicare COVERED service (or clinically needed) is when you are in much pain due to a bad spinal condition. You should also expect Medicare to cover and pay for your rehabilitation as long as you are improving. When you have a COVERED chiropractic spinal adjustment (manipulation treatment), it will be shown on your Medicare claim form and payment reports as either “98940”, “98941”, or “98942”.
PERHAPS COVERED
Your Chiropractic Adjustment must be clinically needed according to Medicare. If Medicare thinks your condition is not “Medically Necessary”, they won’t pay. If we know or believe that Medicare will not pay for your Chiropractic Adjustment due to any rules that they might have, we will let you know. We will give you a special Medicare form known as the Advance Beneficiary Notice (ABN).
STATEMENT OF UNDERSTANDING
I understand that I am personally financially responsible for all Medicare NON-covered services. I also understand that there could be times when my chiropractic adjustments might not be covered. If so, my doctor will let me know. I am also responsible for any annual deductibles or applicable copayments as required by Medicare.
By signing below, I hereby authorize that all of the information stated about myself is truthful, and that I have read and agree to the above statements outlined in this form:
Initial Patient Record
Financial Agreement
Assignment of Benefits
HIPAA Notice
Chiropractic Informed Consent
About Medicare
Please fill out the information below to the best of your capability. The more details we have about you and your lifestyle, history, and surroundings, the better we can understand how to treat you. Get in touch with us by calling our office at 512-268-2768.
We are looking forward to you experiencing the magic of Benevida!
New Patient (No Insurance)
Patient Information
Initial Problem Record
Medical History and Present Medical Condition Questionnaire
Additional Health and Lifestyle Questions
Trauma History
Financial Agreement
This office is committed to providing you with the best possible medical care, and we are available to discuss our professional
fees with you at any time. Your clear understanding of our financial policy is important to our professional relationship.
WE ACCEPT CASH, LOCAL CHECKS, CREDIT CARDS (VISA, MASTERCARD, DISCOVER, AMEX), AND CARECREDIT
PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED, UNLESS PRIOR ARRANGEMENTS HAVE BEEN MADE
INSURANCE IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANY
We do not accept assignment for Medicare, however, we will charge our cash prices and electronically submit an insurance claim for you – as a courtesy to you. During your chiropractic visit, you will receive extra care in addition to your adjustment.
We perform several procedure codes; however Medicare covers the adjustment code ONLY. Typically you will be mailed a partial refund, between $24-$26 for your adjustment along with a letter explaining your benefits.
We accept assignment for Workers’ Compensation and most Medical Insurances. We will electronically bill your insurance company for payment, but we are not a party to your insurance contract. Again, we will bill your insurance company as a courtesy to you. You will still be responsible for deductibles, and any and all services, not covered by your insurance company.
Pre-Payments: Patient is entitled to a reimbursement for services not rendered, however all used sessions will be billed at the non-discounted rate and refunded remaining balance.
MISSED APPOINTMENTS
As a courtesy to your fellow patients and to our staff, we require at least 24 hours notice of cancellation of any appointment. Unless your appointment is cancelled at least 24 hours in advance we will charge you at the rate of a normal office visit (insurance does not cover missed appointments.) Please help us serve you better by keeping your scheduled appointments.
PATIENT LIENS
I fully understand that I am directly responsible to Bene Vida Health + Wellness Center for all medical bills submitted by them for services rendered to me. Further, this agreement is made solely for this facility and it’s practices, additional protection and in consideration of awaiting payment.
Should any of my account balances be turned over for collections, I agree that I will be responsible for all attorney fees, court costs, collection fees, certified mailing fees and interest that is accrued on my balance until paid in full at 18% per anum.
Chiropractic Informed Consent
The nature of the chiropractic manipulation: I will use my hands or instrument to move joints of
your body. This may result in an audible “pop” or “click”.
The material risk inherent in an adjustment: As with any health care procedure, there are certain
complications that may arise during a chiropractic manipulation. This may include strains, dislocations,
fractures, disc injuries, and strokes. This list in not all conclusive.
The probability of those risks: Fractures are rare and can result from an underlying weakness in
the bones. The other complications are considered rare. One source states that stroke is a possible
occurrence in 1/1,000,000 cases or higher. We employ tests during our examination to identify if you
may be susceptible to that kind of injury.
Ancillary treatment recommended: Manipulations, cervical rehabilitation, cervical traction, lumbar
traction, lumbar rehabilitation, manual therapy, electrical modalities, physical modalities, ice therapy,
and heat therapy.
Other treatment options for your condition may include: Medical care with prescription drugs,
self-management with over-the-counter medication, rest and/or surgery. There is material risk
inherent in each of these options, including but not limited to, addiction to medications, side effects of
medication, improper self-dosage, and surgical risk, including complications from the procedure and
the anesthesia.
I have read or have had read to me the above explanation of the chiropractic adjustment and the
related treatment. I have discussed with the doctor and have had my questions answered to my
satisfaction. By signing below, I state that I have weighted the risks involved in undergoing treatment
and I have decided that it was in my best interest to undergo the treatment recommended. Having
been informed of the risks, I hereby give my consent to treatment.
HIPAA Notice
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.
In the course of your care as a patient at Well Connected Chiropractic we may use or disclose personal and health related information about you in the following ways;
1. Your protected health information, including your clinical records, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assessment or treatment.
2. Your health care records as well as your billing records may be disclosed to another party, such as an insurance carrier, agent, adjuster, HMO, PPO, or your employer, if they maybe responsible for the payment of services provided to you.
3. Your name, address, phone number, and your health care records may be used by our office only to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information.
You have a right to request restrictions on our use of your protected health information for treatment, payment and operations purposes. Such requests are not automatic and require the notice to this office.
Your name, address, telephone number, e-mail address and health records may be used to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information that maybe of interest to you. If you are not home to receive an appointment reminder or other related information, a message may be left on your answering machine or with a person in your household.
You have a right to confidential communications and to request restrictions relative to such contacts. You also have the right to be contacted by alternative means or at alternative locations.
We are permitted and may be required to use or disclose your health information without your authorization in these following circumstances:
1. If we provide health care services to you in an emergency.
2. If we are required by law to provide care to you and we are unable obtain your consent after attempting to do so.
3. If there are substantial barriers to communicating with you, but in our professional judgment we believe that you intend for us to provide care.
4. If we are ordered by the courts or another appropriate agency.
You have the right to receive an accounting of any such disclosures made by this office. Any use or disclosure of your protected health information, other than as outlined above, will only be made upon your written authorization. If you provide an authorization for release of information you have the right to revoke that authorization at a later date. Information that we use or disclose based on this privacy notice may be subject to re-disclosure by the person to whom we provide the information and may no longer be protected by the federal privacy rules. We normally provide information about your health to you in person at the time you receive chiropractic care from us. We may also mail information to you regarding your health care or about the status of your account. If you would like to receive this information at an address other than your home or if you would like the information in a specific form please advise us in writing.
You have the right to inspect and/or copy your health information for as long as the information remains in our files. In addition you have the right to request an amendment to your health information.
Requests to inspect, copy or amend your health related information should be provided to us in writing. We are required by state and federal law to maintain the privacy of your patient file and the health protected health information therein.
We are also required to provide you with this notice of our privacy practices with respect to your health information.
We are further required by law to abide by the terms of this notice while it is in effect. We reserve the right to alter or amend the terms of this privacy notice. If changes are made to our privacy notice we will notify you in writing as soon as possible following the changes. Any change in our privacy notice will apply for all your health information in our files. If you have a complaint regarding our privacy notice, our privacy practices or any aspect of our privacy activities you should direct your complaint to: If you would like further information about our privacy policies and practices please contact: You also have the right to lodge a complaint with the Secretary of the Department of Health and Human Services. If you choose to lodge a complaint with this office or with the Secretary your care will continue and you will not be disadvantaged by this office or our staff in any manner whatsoever.
This notice is effective as of April 2003, and any alterations or amendments made hereto will expire seven years after the date upon which the record was created.
My initials acknowledge that I have received a copy of this notice.
By signing below, I hereby authorize that all of the information stated about myself is truthful, and that I have read and agree to the above statements outlined in this form:
Initial Patient Record
Financial Agreement
No Show Policy
HIPAA Notice
Please fill out the information below to the best of your capability. The more details we have about you and your lifestyle, history, and surroundings, the better we can understand how to treat you. Get in touch with us by calling our office at 512-268-2768.
We are looking forward to you experiencing the magic of Benevida!
Intake (Insurance)
Patient Information
Initial Problem Record
Medical History and Present Medical Condition Questionnaire
Additional Health and Lifestyle Questions
Trauma History
Financial Agreement
This office is committed to providing you with the best possible medical care, and we are available to discuss our professional
fees with you at any time. Your clear understanding of our financial policy is important to our professional relationship.
WE ACCEPT CASH, LOCAL CHECKS, CREDIT CARDS (VISA, MASTERCARD, DISCOVER, AMEX), AND CARECREDIT
PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED, UNLESS PRIOR ARRANGEMENTS HAVE BEEN MADE
INSURANCE IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANY
We do not accept assignment for Medicare, however, we will charge our cash prices and electronically submit an insurance claim for you – as a courtesy to you. During your chiropractic visit, you will receive extra care in addition to your adjustment.
We perform several procedure codes; however Medicare covers the adjustment code ONLY. Typically you will be mailed a partial refund, between $24-$26 for your adjustment along with a letter explaining your benefits.
We accept assignment for Workers’ Compensation and most Medical Insurances. We will electronically bill your insurance company for payment, but we are not a party to your insurance contract. Again, we will bill your insurance company as a courtesy to you. You will still be responsible for deductibles, and any and all services, not covered by your insurance company.
PRE-PAYMENTS
Patient is entitled to a reimbursement for services not rendered, however all used sessions will be billed at the
non-discounted rate and refunded remaining balance.
MISSED APPOINTMENTS
As a courtesy to your fellow patients and to our staff, we require at least 24 hours notice of cancellation of any appointment. Unless your appointment is cancelled at least 24 hours in advance we will charge you at the rate of a normal office visit (insurance does not cover missed appointments.) Please help us serve you better by keeping your scheduled appointments.
PATIENT LIENS
I fully understand that I am directly responsible to Bene Vida Health + Wellness Center for all medical bills submitted by them for services rendered to me. Further, this agreement is made solely for this facility and it’s practices, additional protection and in consideration of awaiting payment.
Should any of my account balances be turned over for collections, I agree that I will be responsible for all attorney fees, court costs, collection fees, certified mailing fees and interest that is accrued on my balance until paid in full at 18% per anum.
Chiropractic Informed Consent
The nature of the chiropractic manipulation: I will use my hands or instrument to move joints of your body. This may result in an audible “pop” or “click”.
The material risk inherent in an adjustment: As with any health care procedure, there are certain complications that may arise during a chiropractic manipulation. This may include strains, dislocations, fractures, disc injuries, and strokes. This list in not all conclusive.
The probability of those risks: Fractures are rare and can result from an underlying weakness in the bones. The other complications are considered rare. One source states that stroke is a possible occurrence in 1/1,000,000 cases or higher. We employ tests during our examination to identify if you may be susceptible to that kind of injury.
Ancillary treatment recommended: Manipulations, cervical rehabilitation, cervical traction, lumbar traction, lumbar rehabilitation, manual therapy, electrical modalities, physical modalities, ice therapy, and heat therapy.
Other treatment options for your condition may include: Medical care with prescription drugs, self-management with over-the-counter medication, rest and/or surgery. There is material risk inherent in each of these options, including but not limited to, addiction to medications, side effects of medication, improper self-dosage, and surgical risk, including complications from the procedure and the anesthesia.
I have read or have had read to me the above explanation of the chiropractic adjustment and the related treatment. I have discussed with the doctor and have had my questions answered to my satisfaction. By signing below, I state that I have weighted the risks involved in undergoing treatment and I have decided that it was in my best interest to undergo the treatment recommended. Having been informed of the risks, I hereby give my consent to treatment.
HIPAA Notice
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.
In the course of your care as a patient at Well Connected Chiropractic we may use or disclose personal and health related information about you in the following ways;
1. Your protected health information, including your clinical records, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assessment or treatment.
2. Your health care records as well as your billing records may be disclosed to another party, such as an insurance carrier, agent, adjuster, HMO, PPO, or your employer, if they maybe responsible for the payment of services provided to you.
3. Your name, address, phone number, and your health care records may be used by our office only to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information.
You have a right to request restrictions on our use of your protected health information for treatment, payment and operations purposes. Such requests are not automatic and require the notice to this office.
Your name, address, telephone number, e-mail address and health records may be used to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information that maybe of interest to you. If you are not home to receive an appointment reminder or other related information, a message may be left on your answering machine or with a person in your household.
You have a right to confidential communications and to request restrictions relative to such contacts. You also have the right to be contacted by alternative means or at alternative locations.
We are permitted and may be required to use or disclose your health information without your authorization in these following circumstances:
1. If we provide health care services to you in an emergency.
2. If we are required by law to provide care to you and we are unable obtain your consent after attempting to do so.
3. If there are substantial barriers to communicating with you, but in our professional judgment we believe that you intend for us to provide care.
4. If we are ordered by the courts or another appropriate agency.
You have the right to receive an accounting of any such disclosures made by this office. Any use or disclosure of your protected health information, other than as outlined above, will only be made upon your written authorization. If you provide an authorization for release of information you have the right to revoke that authorization at a later date. Information that we use or disclose based on this privacy notice may be subject to re-disclosure by the person to whom we provide the information and may no longer be protected by the federal privacy rules. We normally provide information about your health to you in person at the time you receive chiropractic care from us. We may also mail information to you regarding your health care or about the status of your account. If you would like to receive this information at an address other than your home or if you would like the information in a specific form please advise us in writing.
You have the right to inspect and/or copy your health information for as long as the information remains in our files. In addition you have the right to request an amendment to your health information.
Requests to inspect, copy or amend your health related information should be provided to us in writing. We are required by state and federal law to maintain the privacy of your patient file and the health protected health information therein.
We are also required to provide you with this notice of our privacy practices with respect to your health information.
We are further required by law to abide by the terms of this notice while it is in effect. We reserve the right to alter or amend the terms of this privacy notice. If changes are made to our privacy notice we will notify you in writing as soon as possible following the changes. Any change in our privacy notice will apply for all your health information in our files. If you have a complaint regarding our privacy notice, our privacy practices or any aspect of our privacy activities you should direct your complaint to: If you would like further information about our privacy policies and practices please contact: You also have the right to lodge a complaint with the Secretary of the Department of Health and Human Services. If you choose to lodge a complaint with this office or with the Secretary your care will continue and you will not be disadvantaged by this office or our staff in any manner whatsoever.
This notice is effective as of April 2003, and any alterations or amendments made hereto will expire seven years after the date upon which the record was created.
My initials acknowledge that I have received a copy of this notice.
Assignment of Benefits
ASSIGNMENT OF BENEFITS and RELEASE OF AUTHORIZATION
I hereby authorize my insurance company to make payments to Benevida Chiropractic for chiropractic or massage services rendered to me or my dependents, if applicable. Should my insurance carrier deny Benevida Chiropractic payment, I understand that I am financially responsible for all charges. I authorize Benevida Chiropractic to release any and all of my records to my insurer, or any third party payer, legally responsible for the payment of chiropractic or massage. I certify that the information provided or to be provided by me is correct and complete to the best of my knowledge. It is my responsibility to update any and all personal, insurance, and health information. I agree that a photocopy of this assignment shall serve in lieu of the original.
By signing below, I hereby authorize that all of the information stated about myself is truthful, and that I have read and agree to the above statements outlined in this form:
Initial Patient Record
Financial Agreement
No Show Policy
Chiropractic Informed Consent
HIPAA Notice
Assignment of Benefits
Please fill out the information below to the best of your capability. The more details we have about you and your lifestyle, history, and surroundings, the better we can understand how to treat you. Get in touch with us by calling our office at 512-268-2768.
We are looking forward to you experiencing the magic of Benevida!
Intake (Insurance)
Patient Information
Initial Problem Record
Medical History and Present Medical Condition Questionnaire
Additional Health and Lifestyle Questions
Trauma History
Financial Agreement
This office is committed to providing you with the best possible medical care, and we are available to discuss our professional
fees with you at any time. Your clear understanding of our financial policy is important to our professional relationship.
WE ACCEPT CASH, LOCAL CHECKS, CREDIT CARDS (VISA, MASTERCARD, DISCOVER, AMEX), AND CARECREDIT
PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED, UNLESS PRIOR ARRANGEMENTS HAVE BEEN MADE
INSURANCE IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANY
We do not accept assignment for Medicare, however, we will charge our cash prices and electronically submit an insurance claim for you – as a courtesy to you. During your chiropractic visit, you will receive extra care in addition to your adjustment.
We perform several procedure codes; however Medicare covers the adjustment code ONLY. Typically you will be mailed a partial refund, between $24-$26 for your adjustment along with a letter explaining your benefits.
We accept assignment for Workers’ Compensation and most Medical Insurances. We will electronically bill your insurance company for payment, but we are not a party to your insurance contract. Again, we will bill your insurance company as a courtesy to you. You will still be responsible for deductibles, and any and all services, not covered by your insurance company.
PRE-PAYMENTS
Patient is entitled to a reimbursement for services not rendered, however all used sessions will be billed at the
non-discounted rate and refunded remaining balance.
MISSED APPOINTMENTS
As a courtesy to your fellow patients and to our staff, we require at least 24 hours notice of cancellation of any appointment. Unless your appointment is cancelled at least 24 hours in advance we will charge you at the rate of a normal office visit (insurance does not cover missed appointments.) Please help us serve you better by keeping your scheduled appointments.
PATIENT LIENS
I fully understand that I am directly responsible to Bene Vida Health + Wellness Center for all medical bills submitted by them for services rendered to me. Further, this agreement is made solely for this facility and it’s practices, additional protection and in consideration of awaiting payment.
Should any of my account balances be turned over for collections, I agree that I will be responsible for all attorney fees, court costs, collection fees, certified mailing fees and interest that is accrued on my balance until paid in full at 18% per anum.
Chiropractic Informed Consent
The nature of the chiropractic manipulation: I will use my hands or instrument to move joints of your body. This may result in an audible “pop” or “click”.
The material risk inherent in an adjustment: As with any health care procedure, there are certain complications that may arise during a chiropractic manipulation. This may include strains, dislocations, fractures, disc injuries, and strokes. This list in not all conclusive.
The probability of those risks: Fractures are rare and can result from an underlying weakness in the bones. The other complications are considered rare. One source states that stroke is a possible occurrence in 1/1,000,000 cases or higher. We employ tests during our examination to identify if you may be susceptible to that kind of injury.
Ancillary treatment recommended: Manipulations, cervical rehabilitation, cervical traction, lumbar traction, lumbar rehabilitation, manual therapy, electrical modalities, physical modalities, ice therapy, and heat therapy.
Other treatment options for your condition may include: Medical care with prescription drugs, self-management with over-the-counter medication, rest and/or surgery. There is material risk inherent in each of these options, including but not limited to, addiction to medications, side effects of medication, improper self-dosage, and surgical risk, including complications from the procedure and the anesthesia.
I have read or have had read to me the above explanation of the chiropractic adjustment and the related treatment. I have discussed with the doctor and have had my questions answered to my satisfaction. By signing below, I state that I have weighted the risks involved in undergoing treatment and I have decided that it was in my best interest to undergo the treatment recommended. Having been informed of the risks, I hereby give my consent to treatment.
HIPAA Notice
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.
In the course of your care as a patient at Well Connected Chiropractic we may use or disclose personal and health related information about you in the following ways;
1. Your protected health information, including your clinical records, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assessment or treatment.
2. Your health care records as well as your billing records may be disclosed to another party, such as an insurance carrier, agent, adjuster, HMO, PPO, or your employer, if they maybe responsible for the payment of services provided to you.
3. Your name, address, phone number, and your health care records may be used by our office only to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information.
You have a right to request restrictions on our use of your protected health information for treatment, payment and operations purposes. Such requests are not automatic and require the notice to this office.
Your name, address, telephone number, e-mail address and health records may be used to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information that maybe of interest to you. If you are not home to receive an appointment reminder or other related information, a message may be left on your answering machine or with a person in your household.
You have a right to confidential communications and to request restrictions relative to such contacts. You also have the right to be contacted by alternative means or at alternative locations.
We are permitted and may be required to use or disclose your health information without your authorization in these following circumstances:
1. If we provide health care services to you in an emergency.
2. If we are required by law to provide care to you and we are unable obtain your consent after attempting to do so.
3. If there are substantial barriers to communicating with you, but in our professional judgment we believe that you intend for us to provide care.
4. If we are ordered by the courts or another appropriate agency.
You have the right to receive an accounting of any such disclosures made by this office. Any use or disclosure of your protected health information, other than as outlined above, will only be made upon your written authorization. If you provide an authorization for release of information you have the right to revoke that authorization at a later date. Information that we use or disclose based on this privacy notice may be subject to re-disclosure by the person to whom we provide the information and may no longer be protected by the federal privacy rules. We normally provide information about your health to you in person at the time you receive chiropractic care from us. We may also mail information to you regarding your health care or about the status of your account. If you would like to receive this information at an address other than your home or if you would like the information in a specific form please advise us in writing.
You have the right to inspect and/or copy your health information for as long as the information remains in our files. In addition you have the right to request an amendment to your health information.
Requests to inspect, copy or amend your health related information should be provided to us in writing. We are required by state and federal law to maintain the privacy of your patient file and the health protected health information therein.
We are also required to provide you with this notice of our privacy practices with respect to your health information.
We are further required by law to abide by the terms of this notice while it is in effect. We reserve the right to alter or amend the terms of this privacy notice. If changes are made to our privacy notice we will notify you in writing as soon as possible following the changes. Any change in our privacy notice will apply for all your health information in our files. If you have a complaint regarding our privacy notice, our privacy practices or any aspect of our privacy activities you should direct your complaint to: If you would like further information about our privacy policies and practices please contact: You also have the right to lodge a complaint with the Secretary of the Department of Health and Human Services. If you choose to lodge a complaint with this office or with the Secretary your care will continue and you will not be disadvantaged by this office or our staff in any manner whatsoever.
This notice is effective as of April 2003, and any alterations or amendments made hereto will expire seven years after the date upon which the record was created.
My initials acknowledge that I have received a copy of this notice.
Assignment of Benefits
ASSIGNMENT OF BENEFITS and RELEASE OF AUTHORIZATION
I hereby authorize my insurance company to make payments to Benevida Chiropractic for chiropractic or massage services rendered to me or my dependents, if applicable. Should my insurance carrier deny Benevida Chiropractic payment, I understand that I am financially responsible for all charges. I authorize Benevida Chiropractic to release any and all of my records to my insurer, or any third party payer, legally responsible for the payment of chiropractic or massage. I certify that the information provided or to be provided by me is correct and complete to the best of my knowledge. It is my responsibility to update any and all personal, insurance, and health information. I agree that a photocopy of this assignment shall serve in lieu of the original.
By signing below, I hereby authorize that all of the information stated about myself is truthful, and that I have read and agree to the above statements outlined in this form:
Initial Patient Record
Financial Agreement
No Show Policy
Chiropractic Informed Consent
HIPAA Notice
Assignment of Benefits
Please fill out the information below to the best of your capability. The more details we have about you and your lifestyle, history, and surroundings, the better we can understand how to treat you. Get in touch with us by calling our office at 512-268-2768.
We are looking forward to you experiencing the magic of Benevida!
New Patient (No Insurance)
Patient Information
Initial Problem Record
Medical History and Present Medical Condition Questionnaire
Additional Health and Lifestyle Questions
Trauma History
Financial Agreement
This office is committed to providing you with the best possible medical care, and we are available to discuss our professional
fees with you at any time. Your clear understanding of our financial policy is important to our professional relationship.
WE ACCEPT CASH, LOCAL CHECKS, CREDIT CARDS (VISA, MASTERCARD, DISCOVER, AMEX), AND CARECREDIT
PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED, UNLESS PRIOR ARRANGEMENTS HAVE BEEN MADE
INSURANCE IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANY
We do not accept assignment for Medicare, however, we will charge our cash prices and electronically submit an insurance claim for you – as a courtesy to you. During your chiropractic visit, you will receive extra care in addition to your adjustment.
We perform several procedure codes; however Medicare covers the adjustment code ONLY. Typically you will be mailed a partial refund, between $24-$26 for your adjustment along with a letter explaining your benefits.
We accept assignment for Workers’ Compensation and most Medical Insurances. We will electronically bill your insurance company for payment, but we are not a party to your insurance contract. Again, we will bill your insurance company as a courtesy to you. You will still be responsible for deductibles, and any and all services, not covered by your insurance company.
Pre-Payments: Patient is entitled to a reimbursement for services not rendered, however all used sessions will be billed at the non-discounted rate and refunded remaining balance.
MISSED APPOINTMENTS
As a courtesy to your fellow patients and to our staff, we require at least 24 hours notice of cancellation of any appointment. Unless your appointment is cancelled at least 24 hours in advance we will charge you at the rate of a normal office visit (insurance does not cover missed appointments.) Please help us serve you better by keeping your scheduled appointments.
PATIENT LIENS
I fully understand that I am directly responsible to Bene Vida Health + Wellness Center for all medical bills submitted by them for services rendered to me. Further, this agreement is made solely for this facility and it’s practices, additional protection and in consideration of awaiting payment.
Should any of my account balances be turned over for collections, I agree that I will be responsible for all attorney fees, court costs, collection fees, certified mailing fees and interest that is accrued on my balance until paid in full at 18% per anum.
Chiropractic Informed Consent
The nature of the chiropractic manipulation: I will use my hands or instrument to move joints of
your body. This may result in an audible “pop” or “click”.
The material risk inherent in an adjustment: As with any health care procedure, there are certain
complications that may arise during a chiropractic manipulation. This may include strains, dislocations,
fractures, disc injuries, and strokes. This list in not all conclusive.
The probability of those risks: Fractures are rare and can result from an underlying weakness in
the bones. The other complications are considered rare. One source states that stroke is a possible
occurrence in 1/1,000,000 cases or higher. We employ tests during our examination to identify if you
may be susceptible to that kind of injury.
Ancillary treatment recommended: Manipulations, cervical rehabilitation, cervical traction, lumbar
traction, lumbar rehabilitation, manual therapy, electrical modalities, physical modalities, ice therapy,
and heat therapy.
Other treatment options for your condition may include: Medical care with prescription drugs,
self-management with over-the-counter medication, rest and/or surgery. There is material risk
inherent in each of these options, including but not limited to, addiction to medications, side effects of
medication, improper self-dosage, and surgical risk, including complications from the procedure and
the anesthesia.
I have read or have had read to me the above explanation of the chiropractic adjustment and the
related treatment. I have discussed with the doctor and have had my questions answered to my
satisfaction. By signing below, I state that I have weighted the risks involved in undergoing treatment
and I have decided that it was in my best interest to undergo the treatment recommended. Having
been informed of the risks, I hereby give my consent to treatment.
HIPAA Notice
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.
In the course of your care as a patient at Well Connected Chiropractic we may use or disclose personal and health related information about you in the following ways;
1. Your protected health information, including your clinical records, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assessment or treatment.
2. Your health care records as well as your billing records may be disclosed to another party, such as an insurance carrier, agent, adjuster, HMO, PPO, or your employer, if they maybe responsible for the payment of services provided to you.
3. Your name, address, phone number, and your health care records may be used by our office only to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information.
You have a right to request restrictions on our use of your protected health information for treatment, payment and operations purposes. Such requests are not automatic and require the notice to this office.
Your name, address, telephone number, e-mail address and health records may be used to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information that maybe of interest to you. If you are not home to receive an appointment reminder or other related information, a message may be left on your answering machine or with a person in your household.
You have a right to confidential communications and to request restrictions relative to such contacts. You also have the right to be contacted by alternative means or at alternative locations.
We are permitted and may be required to use or disclose your health information without your authorization in these following circumstances:
1. If we provide health care services to you in an emergency.
2. If we are required by law to provide care to you and we are unable obtain your consent after attempting to do so.
3. If there are substantial barriers to communicating with you, but in our professional judgment we believe that you intend for us to provide care.
4. If we are ordered by the courts or another appropriate agency.
You have the right to receive an accounting of any such disclosures made by this office. Any use or disclosure of your protected health information, other than as outlined above, will only be made upon your written authorization. If you provide an authorization for release of information you have the right to revoke that authorization at a later date. Information that we use or disclose based on this privacy notice may be subject to re-disclosure by the person to whom we provide the information and may no longer be protected by the federal privacy rules. We normally provide information about your health to you in person at the time you receive chiropractic care from us. We may also mail information to you regarding your health care or about the status of your account. If you would like to receive this information at an address other than your home or if you would like the information in a specific form please advise us in writing.
You have the right to inspect and/or copy your health information for as long as the information remains in our files. In addition you have the right to request an amendment to your health information.
Requests to inspect, copy or amend your health related information should be provided to us in writing. We are required by state and federal law to maintain the privacy of your patient file and the health protected health information therein.
We are also required to provide you with this notice of our privacy practices with respect to your health information.
We are further required by law to abide by the terms of this notice while it is in effect. We reserve the right to alter or amend the terms of this privacy notice. If changes are made to our privacy notice we will notify you in writing as soon as possible following the changes. Any change in our privacy notice will apply for all your health information in our files. If you have a complaint regarding our privacy notice, our privacy practices or any aspect of our privacy activities you should direct your complaint to: If you would like further information about our privacy policies and practices please contact: You also have the right to lodge a complaint with the Secretary of the Department of Health and Human Services. If you choose to lodge a complaint with this office or with the Secretary your care will continue and you will not be disadvantaged by this office or our staff in any manner whatsoever.
This notice is effective as of April 2003, and any alterations or amendments made hereto will expire seven years after the date upon which the record was created.
My initials acknowledge that I have received a copy of this notice.
By signing below, I hereby authorize that all of the information stated about myself is truthful, and that I have read and agree to the above statements outlined in this form:
Initial Patient Record
Financial Agreement
No Show Policy
HIPAA Notice
Please fill out the information below to the best of your capability. The more details we have about you and your lifestyle, history, and surroundings, the better we can understand how to treat you. Get in touch with us by calling our office at 512-268-2768.
We are looking forward to you experiencing the magic of Benevida!
New Patient (Medicare)
Patient Information
Initial Problem Record
Medical History and Present Medical Condition Questionnaire
Additional Health and Lifestyle Questions
Trauma History
Financial Agreement
This office is committed to providing you with the best possible medical care, and we are available to discuss our professional
fees with you at any time. Your clear understanding of our financial policy is important to our professional relationship.
WE ACCEPT CASH, LOCAL CHECKS, CREDIT CARDS (VISA, MASTERCARD, DISCOVER, AMEX), AND CARECREDIT
PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED, UNLESS PRIOR ARRANGEMENTS HAVE BEEN MADE INSURANCE IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANY
We do not accept assignment for Medicare, however, we will charge our cash prices and electronically submit an insurance claim for you – as a courtesy to you. During your chiropractic visit, you will receive extra care in addition to your adjustment.
We perform several procedure codes; however Medicare covers the adjustment code ONLY. Typically you will be mailed a partial refund, between $24-$26 for your adjustment along with a letter explaining your benefits.
We accept assignment for Workers’ Compensation and most Medical Insurances. We will electronically bill your insurance company for payment, but we are not a party to your insurance contract. Again, we will bill your insurance company as a courtesy to you. You will still be responsible for deductibles, and any and all services, not covered by your insurance company.
PRE-PAYMENTS: Patient is entitled to a reimbursement for services not rendered, however all used sessions will be billed at the non-discounted rate and refunded remaining balance.
MISSED APPOINTMENTS
As a courtesy to your fellow patients and to our staff, we require at least 24 hours notice of cancellation of any appointment.
Unless your appointment is cancelled at least 24 hours in advance we will charge you at the rate of a normal office visit (insurance does not cover missed appointments.) Please help us serve you better by keeping your scheduled appointments.
PATIENT LIENS
I fully understand that I am directly responsible to Bene Vida Health + Wellness Center for all medical bills submitted by them for services rendered to me. Further, this agreement is made solely for this facility and it’s practices, additional protection and in consideration of awaiting payment.
Should any of my account balances be turned over for collections, I agree that I will be responsible for all attorney fees, court costs, collection fees, certified mailing fees and interest that is accrued on my balance until paid in full at 18% per anum.
Assignment of Benefits
ASSIGNMENT OF BENEFITS and RELEASE OF AUTHORIZATION
I hereby authorize my insurance company to make payments to Benevida Chiropractic for chiropractic or massage services rendered to me or my dependents, if applicable. Should my insurance carrier deny Benevida Chiropractic payment, I understand that I am financially responsible for all charges. I authorize Benevida Chiropractic to release any and all of my records to my insurer, or any third party payer, legally responsible for the payment of chiropractic or massage. I certify that the information provided or to be provided by me is correct and complete to the best of my knowledge. It is my responsibility to update any and all personal, insurance, and health information. I agree that a photocopy of this assignment shall serve in lieu of the original.
HIPAA Notice
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.
In the course of your care as a patient at Well Connected Chiropractic we may use or disclose personal and health related information about you in the following ways;
1. Your protected health information, including your clinical records, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assessment or treatment.
2. Your health care records as well as your billing records may be disclosed to another party, such as an insurance carrier, agent, adjuster, HMO, PPO, or your employer, if they maybe responsible for the payment of services provided to you.
3. Your name, address, phone number, and your health care records may be used by our office only to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information.
You have a right to request restrictions on our use of your protected health information for treatment, payment and operations purposes. Such requests are not automatic and require the notice to this office.
Your name, address, telephone number, e-mail address and health records may be used to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information that maybe of interest to you. If you are not home to receive an appointment reminder or other related information, a message may be left on your answering machine or with a person in your household.
You have a right to confidential communications and to request restrictions relative to such contacts. You also have the right to be contacted by alternative means or at alternative locations.
We are permitted and may be required to use or disclose your health information without your authorization in these following circumstances:
1. If we provide health care services to you in an emergency.
2. If we are required by law to provide care to you and we are unable obtain your consent after attempting to do so.
3. If there are substantial barriers to communicating with you, but in our professional judgment we believe that you intend for us to provide care.
4. If we are ordered by the courts or another appropriate agency.
You have the right to receive an accounting of any such disclosures made by this office. Any use or disclosure of your protected health information, other than as outlined above, will only be made upon your written authorization. If you provide an authorization for release of information you have the right to revoke that authorization at a later date. Information that we use or disclose based on this privacy notice may be subject to re-disclosure by the person to whom we provide the information and may no longer be protected by the federal privacy rules. We normally provide information about your health to you in person at the time you receive chiropractic care from us. We may also mail information to you regarding your health care or about the status of your account. If you would like to receive this information at an address other than your home or if you would like the information in a specific form please advise us in writing.
You have the right to inspect and/or copy your health information for as long as the information remains in our files. In addition you have the right to request an amendment to your health information.
Requests to inspect, copy or amend your health related information should be provided to us in writing. We are required by state and federal law to maintain the privacy of your patient file and the health protected health information therein.
We are also required to provide you with this notice of our privacy practices with respect to your health information.
We are further required by law to abide by the terms of this notice while it is in effect. We reserve the right to alter or amend the terms of this privacy notice. If changes are made to our privacy notice we will notify you in writing as soon as possible following the changes. Any change in our privacy notice will apply for all your health information in our files. If you have a complaint regarding our privacy notice, our privacy practices or any aspect of our privacy activities you should direct your complaint to: If you would like further information about our privacy policies and practices please contact: You also have the right to lodge a complaint with the Secretary of the Department of Health and Human Services. If you choose to lodge a complaint with this office or with the Secretary your care will continue and you will not be disadvantaged by this office or our staff in any manner whatsoever.
This notice is effective as of April 2003, and any alterations or amendments made hereto will expire seven years after the date upon which the record was created.
My initials acknowledge that I have received a copy of this notice.
Chiropractic Informed Consent
The nature of the chiropractic manipulation: I will use my hands or instrument to move joints of
your body. This may result in an audible “pop” or “click”.
The material risk inherent in an adjustment: As with any health care procedure, there are certain
complications that may arise during a chiropractic manipulation. This may include strains, dislocations,
fractures, disc injuries, and strokes. This list in not all conclusive.
The probability of those risks: Fractures are rare and can result from an underlying weakness in
the bones. The other complications are considered rare. One source states that stroke is a possible
occurrence in 1/1,000,000 cases or higher. We employ tests during our examination to identify if you
may be susceptible to that kind of injury.
Ancillary treatment recommended: Manipulations, cervical rehabilitation, cervical traction, lumbar
traction, lumbar rehabilitation, manual therapy, electrical modalities, physical modalities, ice therapy,
and heat therapy.
Other treatment options for your condition may include: Medical care with prescription drugs,
self-management with over-the-counter medication, rest and/or surgery. There is material risk
inherent in each of these options, including but not limited to, addiction to medications, side effects of
medication, improper self-dosage, and surgical risk, including complications from the procedure and
the anesthesia.
I have read or have had read to me the above explanation of the chiropractic adjustment and the
related treatment. I have discussed with the doctor and have had my questions answered to my
satisfaction. By signing below, I state that I have weighted the risks involved in undergoing treatment
and I have decided that it was in my best interest to undergo the treatment recommended. Having
been informed of the risks, I hereby give my consent to treatment.
About Medicare
ABOUT MEDICARE COVERAGE
The government’s Medicare program only pays Doctors of Chiropractic (DCs) for limited services. If your needed Chiropractic Adjustment (manipulation treatment) meets Medicare’s rules, they will usually pay for it. There are three categories of Medicare services: 1.) non-covered 2.) always covered, and 3.) perhaps covered.
NON-COVERED
According to existing Medicare law, most of the available services in our office are NON-COVERED. Hopefully, the U.S. Congress will change that someday and treat Doctors of Chiropractic like all other doctors. Until then:
Examples of Non-Covered Services
All Services Other than Chiropractic Adjustments:
· Office Visits- to evaluate and manage, re-evaluate, advise, or
counsel.
· Physiotherapy- such as massage, traction, electrical
stimulation, neuromuscular re-education, etc.
· X-rays, Laboratory, Supplies, Vitamins, etc.
Various Chiropractic Adjustments:
· Adjustment on an area other than the spine- (to the shoulder, arm, leg, etc.)
· Maintenance Care- you are stable and not making any more improvement.
· Wellness Care- to promote better health.
NON-Covered items will appear on your insurance claim form.
They will show as a Medicare NON-Covered service like this: “72010-GY”. The “72010” code is for an x-ray. The “–GY” code means that it is not-covered, allowing your service to go through the Medicare system. After denial by Medicare, it can then go onto your other insurance. If you have Medigap insurance (also known as Medicare Secondary or Supplemental insurance), they will pay according to the terms of your contract.
ALWAYS COVERED
A Typical example of a Medicare COVERED service (or clinically needed) is when you are in much pain due to a bad spinal condition. You should also expect Medicare to cover and pay for your rehabilitation as long as you are improving. When you have a COVERED chiropractic spinal adjustment (manipulation treatment), it will be shown on your Medicare claim form and payment reports as either “98940”, “98941”, or “98942”.
PERHAPS COVERED
Your Chiropractic Adjustment must be clinically needed according to Medicare. If Medicare thinks your condition is not “Medically Necessary”, they won’t pay. If we know or believe that Medicare will not pay for your Chiropractic Adjustment due to any rules that they might have, we will let you know. We will give you a special Medicare form known as the Advance Beneficiary Notice (ABN).
STATEMENT OF UNDERSTANDING
I understand that I am personally financially responsible for all Medicare NON-covered services. I also understand that there could be times when my chiropractic adjustments might not be covered. If so, my doctor will let me know. I am also responsible for any annual deductibles or applicable copayments as required by Medicare.
By signing below, I hereby authorize that all of the information stated about myself is truthful, and that I have read and agree to the above statements outlined in this form:
Initial Patient Record
Financial Agreement
Assignment of Benefits
HIPAA Notice
Chiropractic Informed Consent
About Medicare
Additional Forms
Personal Injury Form
Section I: General
*Note: we do not bill 3rd parties meaning we WILL NOT bill the other person’s insurance
Section II: Medical Payments
If you have Medical Payments (“MedPay”) through your auto insurance, we highly suggest using this, as it will be used to cover your bill at Benevida Chiropractic regardless of who was at fault, until your MedPay is exhausted.
Section III: Self Pay
If you do not have medical payments, do not wish pursue legal action with an attorney that we work with, and the accident was deemed the other party’s fault, your next option would be getting care as a Self-Pay patient. After the Auto Accident case is closed, the staff will provide you with all necessary documents to submit to your Auto insurance company. This is not a guarantee that all your payments will be reimbursed. For pricing, please call the office (512) 268-2768
Financial Agreement
This office is committed to providing you with the best possible medical care, and we are available to discuss our professional fees with you at any time. Your clear understanding of our financial policy is important to our professional relationship.
WE ACCEPT CASH, LOCAL CHECKS, CREDIT CARDS (VISA, MASTERCARD, DISCOVER, AMEX), AND CARECREDIT
PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED, UNLESS PRIOR ARRANGEMENTS HAVE BEEN MADE
INSURANCE IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANY
We do not accept assignment for Medicare, however, we will charge our cash prices and electronically submit an insurance claim for you – as a courtesy to you. During your chiropractic visit, you will receive extra care in addition to your adjustment.
We perform several procedure codes; however Medicare covers the adjustment code ONLY. Typically you will be mailed a partial refund, between $24-$26 for your adjustment along with a letter explaining your benefits.
We accept assignment for Workers’ Compensation and most Medical Insurances. We will electronically bill your insurance company for payment, but we are not a party to your insurance contract. Again, we will bill your insurance company as a courtesy to you. You will still be responsible for deductibles, and any and all services, not covered by your insurance company.
PRE-PAYMENTS
Patient is entitled to a reimbursement for services not rendered, however all used sessions will be billed at the non-discounted rate and refunded remaining balance.
MISSED APPOINTMENTS
As a courtesy to your fellow patients and to our staff, we require at least 24 hours notice of cancellation of any appointment. Unless your appointment is cancelled at least 24 hours in advance we will charge you at the rate of a normal office visit (insurance does not cover missed appointments.) Please help us serve you better by keeping your scheduled appointments.
PATIENT LIENS
I fully understand that I am directly responsible to Bene Vida Health + Wellness Center for all medical bills submitted by them for services rendered to me. Further, this agreement is made solely for this facility and it’s practices, additional protection and in consideration of awaiting payment.
Should any of my account balances be turned over for collections, I agree that I will be responsible for all attorney fees, court costs, collection fees, certified mailing fees and interest that is accrued on my balance until paid in full at 18% per anum.
Chiropractic Informed Consent
The nature of the chiropractic manipulation: I will use my hands or instrument to move joints of your body. This may result in an audible “pop” or “click”.
The material risk inherent in an adjustment: As with any health care procedure, there are certain complications that may arise during a chiropractic manipulation. This may include strains, dislocations, fractures, disc injuries, and strokes. This list in not all conclusive.
The probability of those risks: Fractures are rare and can result from an underlying weakness in the bones. The other complications are considered rare. One source states that stroke is a possible occurrence in 1/1,000,000 cases or higher. We employ tests during our examination to identify if you may be susceptible to that kind of injury.
Ancillary treatment recommended: Manipulations, cervical rehabilitation, cervical traction, lumbar traction, lumbar rehabilitation, manual therapy, electrical modalities, physical modalities, ice therapy, and heat therapy.
Other treatment options for your condition may include: Medical care with prescription drugs, self-management with over-the-counter medication, rest and/or surgery. There is material risk inherent in each of these options, including but not limited to, addiction to medications, side effects of medication, improper self-dosage, and surgical risk, including complications from the procedure and the anesthesia.
I have read or have had read to me the above explanation of the chiropractic adjustment and the related treatment. I have discussed with the doctor and have had my questions answered to my satisfaction. By signing below, I state that I have weighted the risks involved in undergoing treatment and I have decided that it was in my best interest to undergo the treatment recommended. Having been informed of the risks, I hereby give my consent to treatment.
HIPPA Notice
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.
In the course of your care as a patient at Well Connected Chiropractic we may use or disclose personal and health related information about you in the following ways;
1. Your protected health information, including your clinical records, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assessment or treatment.
2. Your health care records as well as your billing records may be disclosed to another party, such as an insurance carrier, agent, adjuster, HMO, PPO, or your employer, if they maybe responsible for the payment of services provided to you.
3. Your name, address, phone number, and your health care records may be used by our office only to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information.
You have a right to request restrictions on our use of your protected health information for treatment, payment and operations purposes. Such requests are not automatic and require the notice to this office.
Your name, address, telephone number, e-mail address and health records may be used to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information that maybe of interest to you. If you are not home to receive an appointment reminder or other related information, a message may be left on your answering machine or with a person in your household.
You have a right to confidential communications and to request restrictions relative to such contacts. You also have the right to be contacted by alternative means or at alternative locations.
We are permitted and may be required to use or disclose your health information without your authorization in these following circumstances:
1. If we provide health care services to you in an emergency.
2. If we are required by law to provide care to you and we are unable obtain your consent after attempting to do so.
3. If there are substantial barriers to communicating with you, but in our professional judgment we believe that you intend for us to provide care.
4. If we are ordered by the courts or another appropriate agency.
You have the right to receive an accounting of any such disclosures made by this office. Any use or disclosure of your protected health information, other than as outlined above, will only be made upon your written authorization. If you provide an authorization for release of information you have the right to revoke that authorization at a later date. Information that we use or disclose based on this privacy notice may be subject to re-disclosure by the person to whom we provide the information and may no longer be protected by the federal privacy rules. We normally provide information about your health to you in person at the time you receive chiropractic care from us. We may also mail information to you regarding your health care or about the status of your account. If you would like to receive this information at an address other than your home or if you would like the information in a specific form please advise us in writing.
You have the right to inspect and/or copy your health information for as long as the information remains in our files. In addition you have the right to request an amendment to your health information.
Requests to inspect, copy or amend your health related information should be provided to us in writing. We are required by state and federal law to maintain the privacy of your patient file and the health protected health information therein.
We are also required to provide you with this notice of our privacy practices with respect to your health information.
We are further required by law to abide by the terms of this notice while it is in effect. We reserve the right to alter or amend the terms of this privacy notice. If changes are made to our privacy notice we will notify you in writing as soon as possible following the changes. Any change in our privacy notice will apply for all your health information in our files. If you have a complaint regarding our privacy notice, our privacy practices or any aspect of our privacy activities you should direct your complaint to: If you would like further information about our privacy policies and practices please contact: You also have the right to lodge a complaint with the Secretary of the Department of Health and Human Services. If you choose to lodge a complaint with this office or with the Secretary your care will continue and you will not be disadvantaged by this office or our staff in any manner whatsoever.
This notice is effective as of April 2003, and any alterations or amendments made hereto will expire seven years after the date upon which the record was created.
Assignment of Benefits
ASSIGNMENT OF BENEFITS and RELEASE OF AUTHORIZATION
I hereby authorize my insurance company to make payments to Benevida Chiropractic for chiropractic or massage services rendered to me or my dependents, if applicable. Should my insurance carrier deny Benevida Chiropractic payment, I understand that I am financially responsible for all charges. I authorize Benevida Chiropractic to release any and all of my records to my insurer, or any third party payer, legally responsible for the payment of chiropractic or massage. I certify that the information provided or to be provided by me is correct and complete to the best of my knowledge. It is my responsibility to update any and all personal, insurance, and health information. I agree that a photocopy of this assignment shall serve in lieu of the original.
By signing below, I hereby authorize that all of the information stated about myself is truthful, and that I have read and agree to the above statements outlined in this form:
Initial Patient Record
Financial Agreement
No Show Policy
Chiropractic Informed Consent
HIPAA Notice
Personal Injury Form
Section I: General
*Note: we do not bill 3rd parties meaning we WILL NOT bill the other person’s insurance
Section II: Medical Payments
If you have Medical Payments (“MedPay”) through your auto insurance, we highly suggest using this, as it will be used to cover your bill at Benevida Chiropractic regardless of who was at fault, until your MedPay is exhausted.
Section III: Self Pay
If you do not have medical payments, do not wish pursue legal action with an attorney that we work with, and the accident was deemed the other party’s fault, your next option would be getting care as a Self-Pay patient. After the Auto Accident case is closed, the staff will provide you with all necessary documents to submit to your Auto insurance company. This is not a guarantee that all your payments will be reimbursed. For pricing, please call the office (512) 268-2768
Financial Agreement
This office is committed to providing you with the best possible medical care, and we are available to discuss our professional fees with you at any time. Your clear understanding of our financial policy is important to our professional relationship.
WE ACCEPT CASH, LOCAL CHECKS, CREDIT CARDS (VISA, MASTERCARD, DISCOVER, AMEX), AND CARECREDIT
PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED, UNLESS PRIOR ARRANGEMENTS HAVE BEEN MADE
INSURANCE IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANY
We do not accept assignment for Medicare, however, we will charge our cash prices and electronically submit an insurance claim for you – as a courtesy to you. During your chiropractic visit, you will receive extra care in addition to your adjustment.
We perform several procedure codes; however Medicare covers the adjustment code ONLY. Typically you will be mailed a partial refund, between $24-$26 for your adjustment along with a letter explaining your benefits.
We accept assignment for Workers’ Compensation and most Medical Insurances. We will electronically bill your insurance company for payment, but we are not a party to your insurance contract. Again, we will bill your insurance company as a courtesy to you. You will still be responsible for deductibles, and any and all services, not covered by your insurance company.
PRE-PAYMENTS
Patient is entitled to a reimbursement for services not rendered, however all used sessions will be billed at the non-discounted rate and refunded remaining balance.
MISSED APPOINTMENTS
As a courtesy to your fellow patients and to our staff, we require at least 24 hours notice of cancellation of any appointment. Unless your appointment is cancelled at least 24 hours in advance we will charge you at the rate of a normal office visit (insurance does not cover missed appointments.) Please help us serve you better by keeping your scheduled appointments.
PATIENT LIENS
I fully understand that I am directly responsible to Bene Vida Health + Wellness Center for all medical bills submitted by them for services rendered to me. Further, this agreement is made solely for this facility and it’s practices, additional protection and in consideration of awaiting payment.
Should any of my account balances be turned over for collections, I agree that I will be responsible for all attorney fees, court costs, collection fees, certified mailing fees and interest that is accrued on my balance until paid in full at 18% per anum.
Chiropractic Informed Consent
The nature of the chiropractic manipulation: I will use my hands or instrument to move joints of your body. This may result in an audible “pop” or “click”.
The material risk inherent in an adjustment: As with any health care procedure, there are certain complications that may arise during a chiropractic manipulation. This may include strains, dislocations, fractures, disc injuries, and strokes. This list in not all conclusive.
The probability of those risks: Fractures are rare and can result from an underlying weakness in the bones. The other complications are considered rare. One source states that stroke is a possible occurrence in 1/1,000,000 cases or higher. We employ tests during our examination to identify if you may be susceptible to that kind of injury.
Ancillary treatment recommended: Manipulations, cervical rehabilitation, cervical traction, lumbar traction, lumbar rehabilitation, manual therapy, electrical modalities, physical modalities, ice therapy, and heat therapy.
Other treatment options for your condition may include: Medical care with prescription drugs, self-management with over-the-counter medication, rest and/or surgery. There is material risk inherent in each of these options, including but not limited to, addiction to medications, side effects of medication, improper self-dosage, and surgical risk, including complications from the procedure and the anesthesia.
I have read or have had read to me the above explanation of the chiropractic adjustment and the related treatment. I have discussed with the doctor and have had my questions answered to my satisfaction. By signing below, I state that I have weighted the risks involved in undergoing treatment and I have decided that it was in my best interest to undergo the treatment recommended. Having been informed of the risks, I hereby give my consent to treatment.
HIPPA Notice
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.
In the course of your care as a patient at Well Connected Chiropractic we may use or disclose personal and health related information about you in the following ways;
1. Your protected health information, including your clinical records, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assessment or treatment.
2. Your health care records as well as your billing records may be disclosed to another party, such as an insurance carrier, agent, adjuster, HMO, PPO, or your employer, if they maybe responsible for the payment of services provided to you.
3. Your name, address, phone number, and your health care records may be used by our office only to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information.
You have a right to request restrictions on our use of your protected health information for treatment, payment and operations purposes. Such requests are not automatic and require the notice to this office.
Your name, address, telephone number, e-mail address and health records may be used to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information that maybe of interest to you. If you are not home to receive an appointment reminder or other related information, a message may be left on your answering machine or with a person in your household.
You have a right to confidential communications and to request restrictions relative to such contacts. You also have the right to be contacted by alternative means or at alternative locations.
We are permitted and may be required to use or disclose your health information without your authorization in these following circumstances:
1. If we provide health care services to you in an emergency.
2. If we are required by law to provide care to you and we are unable obtain your consent after attempting to do so.
3. If there are substantial barriers to communicating with you, but in our professional judgment we believe that you intend for us to provide care.
4. If we are ordered by the courts or another appropriate agency.
You have the right to receive an accounting of any such disclosures made by this office. Any use or disclosure of your protected health information, other than as outlined above, will only be made upon your written authorization. If you provide an authorization for release of information you have the right to revoke that authorization at a later date. Information that we use or disclose based on this privacy notice may be subject to re-disclosure by the person to whom we provide the information and may no longer be protected by the federal privacy rules. We normally provide information about your health to you in person at the time you receive chiropractic care from us. We may also mail information to you regarding your health care or about the status of your account. If you would like to receive this information at an address other than your home or if you would like the information in a specific form please advise us in writing.
You have the right to inspect and/or copy your health information for as long as the information remains in our files. In addition you have the right to request an amendment to your health information.
Requests to inspect, copy or amend your health related information should be provided to us in writing. We are required by state and federal law to maintain the privacy of your patient file and the health protected health information therein.
We are also required to provide you with this notice of our privacy practices with respect to your health information.
We are further required by law to abide by the terms of this notice while it is in effect. We reserve the right to alter or amend the terms of this privacy notice. If changes are made to our privacy notice we will notify you in writing as soon as possible following the changes. Any change in our privacy notice will apply for all your health information in our files. If you have a complaint regarding our privacy notice, our privacy practices or any aspect of our privacy activities you should direct your complaint to: If you would like further information about our privacy policies and practices please contact: You also have the right to lodge a complaint with the Secretary of the Department of Health and Human Services. If you choose to lodge a complaint with this office or with the Secretary your care will continue and you will not be disadvantaged by this office or our staff in any manner whatsoever.
This notice is effective as of April 2003, and any alterations or amendments made hereto will expire seven years after the date upon which the record was created.
Assignment of Benefits
ASSIGNMENT OF BENEFITS and RELEASE OF AUTHORIZATION
I hereby authorize my insurance company to make payments to Benevida Chiropractic for chiropractic or massage services rendered to me or my dependents, if applicable. Should my insurance carrier deny Benevida Chiropractic payment, I understand that I am financially responsible for all charges. I authorize Benevida Chiropractic to release any and all of my records to my insurer, or any third party payer, legally responsible for the payment of chiropractic or massage. I certify that the information provided or to be provided by me is correct and complete to the best of my knowledge. It is my responsibility to update any and all personal, insurance, and health information. I agree that a photocopy of this assignment shall serve in lieu of the original.
By signing below, I hereby authorize that all of the information stated about myself is truthful, and that I have read and agree to the above statements outlined in this form:
Initial Patient Record
Financial Agreement
No Show Policy
Chiropractic Informed Consent
HIPAA Notice
Please fill out the information below to the best of your capability. The more details we have about you and your lifestyle, history, and surroundings, the better we can understand how to treat you. Get in touch with us by calling our office at 512-268-2768.
We are looking forward to you experiencing the magic of Benevida!
New Patient (Medicare)
Patient Information
Initial Problem Record
Medical History and Present Medical Condition Questionnaire
Additional Health and Lifestyle Questions
Trauma History
Financial Agreement
This office is committed to providing you with the best possible medical care, and we are available to discuss our professional
fees with you at any time. Your clear understanding of our financial policy is important to our professional relationship.
WE ACCEPT CASH, LOCAL CHECKS, CREDIT CARDS (VISA, MASTERCARD, DISCOVER, AMEX), AND CARECREDIT
PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED, UNLESS PRIOR ARRANGEMENTS HAVE BEEN MADE INSURANCE IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANY
We do not accept assignment for Medicare, however, we will charge our cash prices and electronically submit an insurance claim for you – as a courtesy to you. During your chiropractic visit, you will receive extra care in addition to your adjustment.
We perform several procedure codes; however Medicare covers the adjustment code ONLY. Typically you will be mailed a partial refund, between $24-$26 for your adjustment along with a letter explaining your benefits.
We accept assignment for Workers’ Compensation and most Medical Insurances. We will electronically bill your insurance company for payment, but we are not a party to your insurance contract. Again, we will bill your insurance company as a courtesy to you. You will still be responsible for deductibles, and any and all services, not covered by your insurance company.
PRE-PAYMENTS: Patient is entitled to a reimbursement for services not rendered, however all used sessions will be billed at the non-discounted rate and refunded remaining balance.
MISSED APPOINTMENTS
As a courtesy to your fellow patients and to our staff, we require at least 24 hours notice of cancellation of any appointment.
Unless your appointment is cancelled at least 24 hours in advance we will charge you at the rate of a normal office visit (insurance does not cover missed appointments.) Please help us serve you better by keeping your scheduled appointments.
PATIENT LIENS
I fully understand that I am directly responsible to Bene Vida Health + Wellness Center for all medical bills submitted by them for services rendered to me. Further, this agreement is made solely for this facility and it’s practices, additional protection and in consideration of awaiting payment.
Should any of my account balances be turned over for collections, I agree that I will be responsible for all attorney fees, court costs, collection fees, certified mailing fees and interest that is accrued on my balance until paid in full at 18% per anum.
Assignment of Benefits
ASSIGNMENT OF BENEFITS and RELEASE OF AUTHORIZATION
I hereby authorize my insurance company to make payments to Benevida Chiropractic for chiropractic or massage services rendered to me or my dependents, if applicable. Should my insurance carrier deny Benevida Chiropractic payment, I understand that I am financially responsible for all charges. I authorize Benevida Chiropractic to release any and all of my records to my insurer, or any third party payer, legally responsible for the payment of chiropractic or massage. I certify that the information provided or to be provided by me is correct and complete to the best of my knowledge. It is my responsibility to update any and all personal, insurance, and health information. I agree that a photocopy of this assignment shall serve in lieu of the original.
HIPAA Notice
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.
In the course of your care as a patient at Well Connected Chiropractic we may use or disclose personal and health related information about you in the following ways;
1. Your protected health information, including your clinical records, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assessment or treatment.
2. Your health care records as well as your billing records may be disclosed to another party, such as an insurance carrier, agent, adjuster, HMO, PPO, or your employer, if they maybe responsible for the payment of services provided to you.
3. Your name, address, phone number, and your health care records may be used by our office only to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information.
You have a right to request restrictions on our use of your protected health information for treatment, payment and operations purposes. Such requests are not automatic and require the notice to this office.
Your name, address, telephone number, e-mail address and health records may be used to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information that maybe of interest to you. If you are not home to receive an appointment reminder or other related information, a message may be left on your answering machine or with a person in your household.
You have a right to confidential communications and to request restrictions relative to such contacts. You also have the right to be contacted by alternative means or at alternative locations.
We are permitted and may be required to use or disclose your health information without your authorization in these following circumstances:
1. If we provide health care services to you in an emergency.
2. If we are required by law to provide care to you and we are unable obtain your consent after attempting to do so.
3. If there are substantial barriers to communicating with you, but in our professional judgment we believe that you intend for us to provide care.
4. If we are ordered by the courts or another appropriate agency.
You have the right to receive an accounting of any such disclosures made by this office. Any use or disclosure of your protected health information, other than as outlined above, will only be made upon your written authorization. If you provide an authorization for release of information you have the right to revoke that authorization at a later date. Information that we use or disclose based on this privacy notice may be subject to re-disclosure by the person to whom we provide the information and may no longer be protected by the federal privacy rules. We normally provide information about your health to you in person at the time you receive chiropractic care from us. We may also mail information to you regarding your health care or about the status of your account. If you would like to receive this information at an address other than your home or if you would like the information in a specific form please advise us in writing.
You have the right to inspect and/or copy your health information for as long as the information remains in our files. In addition you have the right to request an amendment to your health information.
Requests to inspect, copy or amend your health related information should be provided to us in writing. We are required by state and federal law to maintain the privacy of your patient file and the health protected health information therein.
We are also required to provide you with this notice of our privacy practices with respect to your health information.
We are further required by law to abide by the terms of this notice while it is in effect. We reserve the right to alter or amend the terms of this privacy notice. If changes are made to our privacy notice we will notify you in writing as soon as possible following the changes. Any change in our privacy notice will apply for all your health information in our files. If you have a complaint regarding our privacy notice, our privacy practices or any aspect of our privacy activities you should direct your complaint to: If you would like further information about our privacy policies and practices please contact: You also have the right to lodge a complaint with the Secretary of the Department of Health and Human Services. If you choose to lodge a complaint with this office or with the Secretary your care will continue and you will not be disadvantaged by this office or our staff in any manner whatsoever.
This notice is effective as of April 2003, and any alterations or amendments made hereto will expire seven years after the date upon which the record was created.
My initials acknowledge that I have received a copy of this notice.
Chiropractic Informed Consent
The nature of the chiropractic manipulation: I will use my hands or instrument to move joints of
your body. This may result in an audible “pop” or “click”.
The material risk inherent in an adjustment: As with any health care procedure, there are certain
complications that may arise during a chiropractic manipulation. This may include strains, dislocations,
fractures, disc injuries, and strokes. This list in not all conclusive.
The probability of those risks: Fractures are rare and can result from an underlying weakness in
the bones. The other complications are considered rare. One source states that stroke is a possible
occurrence in 1/1,000,000 cases or higher. We employ tests during our examination to identify if you
may be susceptible to that kind of injury.
Ancillary treatment recommended: Manipulations, cervical rehabilitation, cervical traction, lumbar
traction, lumbar rehabilitation, manual therapy, electrical modalities, physical modalities, ice therapy,
and heat therapy.
Other treatment options for your condition may include: Medical care with prescription drugs,
self-management with over-the-counter medication, rest and/or surgery. There is material risk
inherent in each of these options, including but not limited to, addiction to medications, side effects of
medication, improper self-dosage, and surgical risk, including complications from the procedure and
the anesthesia.
I have read or have had read to me the above explanation of the chiropractic adjustment and the
related treatment. I have discussed with the doctor and have had my questions answered to my
satisfaction. By signing below, I state that I have weighted the risks involved in undergoing treatment
and I have decided that it was in my best interest to undergo the treatment recommended. Having
been informed of the risks, I hereby give my consent to treatment.
About Medicare
ABOUT MEDICARE COVERAGE
The government’s Medicare program only pays Doctors of Chiropractic (DCs) for limited services. If your needed Chiropractic Adjustment (manipulation treatment) meets Medicare’s rules, they will usually pay for it. There are three categories of Medicare services: 1.) non-covered 2.) always covered, and 3.) perhaps covered.
NON-COVERED
According to existing Medicare law, most of the available services in our office are NON-COVERED. Hopefully, the U.S. Congress will change that someday and treat Doctors of Chiropractic like all other doctors. Until then:
Examples of Non-Covered Services
All Services Other than Chiropractic Adjustments:
· Office Visits- to evaluate and manage, re-evaluate, advise, or
counsel.
· Physiotherapy- such as massage, traction, electrical
stimulation, neuromuscular re-education, etc.
· X-rays, Laboratory, Supplies, Vitamins, etc.
Various Chiropractic Adjustments:
· Adjustment on an area other than the spine- (to the shoulder, arm, leg, etc.)
· Maintenance Care- you are stable and not making any more improvement.
· Wellness Care- to promote better health.
NON-Covered items will appear on your insurance claim form.
They will show as a Medicare NON-Covered service like this: “72010-GY”. The “72010” code is for an x-ray. The “–GY” code means that it is not-covered, allowing your service to go through the Medicare system. After denial by Medicare, it can then go onto your other insurance. If you have Medigap insurance (also known as Medicare Secondary or Supplemental insurance), they will pay according to the terms of your contract.
ALWAYS COVERED
A Typical example of a Medicare COVERED service (or clinically needed) is when you are in much pain due to a bad spinal condition. You should also expect Medicare to cover and pay for your rehabilitation as long as you are improving. When you have a COVERED chiropractic spinal adjustment (manipulation treatment), it will be shown on your Medicare claim form and payment reports as either “98940”, “98941”, or “98942”.
PERHAPS COVERED
Your Chiropractic Adjustment must be clinically needed according to Medicare. If Medicare thinks your condition is not “Medically Necessary”, they won’t pay. If we know or believe that Medicare will not pay for your Chiropractic Adjustment due to any rules that they might have, we will let you know. We will give you a special Medicare form known as the Advance Beneficiary Notice (ABN).
STATEMENT OF UNDERSTANDING
I understand that I am personally financially responsible for all Medicare NON-covered services. I also understand that there could be times when my chiropractic adjustments might not be covered. If so, my doctor will let me know. I am also responsible for any annual deductibles or applicable copayments as required by Medicare.
By signing below, I hereby authorize that all of the information stated about myself is truthful, and that I have read and agree to the above statements outlined in this form:
Initial Patient Record
Financial Agreement
Assignment of Benefits
HIPAA Notice
Chiropractic Informed Consent
About Medicare
Hours of Operation:
Monday: 9am - 3pm
Tuesday: 9am - 1pm
Wednesday: 9am - 6pm
Thursday: 9am - 1pm
Friday: 9am - 6pm
Saturday & Sunday: Closed
Monday: 9am - 3pm
Tuesday: 9am - 1pm
Wednesday: 9am - 6pm
Thursday: 9am - 1pm
Friday: 9am - 6pm
Saturday & Sunday: Closed
