INFORMED CONSENT FOR CHIROPRACTIC CARE: A patient, in coming to the doctor of chiropractic gives the doctor permission and authority to care for the patient in accordance with the chiropractic tests, diagnosis and analysis. The chiropractic adjustment or other clinical procedures are usually beneficial and seldom cause any problem. In rare cases, underlying physical defects, deformities or pathologies may render the patient susceptible to injury. The doctor, of course, will not give a chiropractic adjustment, or health care, if he/she is aware that such care may be contraindicated. Again, it is the responsibility of the patient to make it known or to learn through health care procedures whatever he/she is suffering from: latent pathological defects, illnesses, or deformities which would otherwise not come to the attention of the doctor of chiropractic. The patient should look to the correct specialist for the proper diagnostic and clinical procedures. The doctor of chiropractic provides a specialized, non-duplicating health service. The doctor of chiropractic is licensed in a special practice and is available to work with other types of providers in your health care regime. (Full policy is available on request, posted in the waiting room, and on the back of his form)
DOCTOR-PATIENT RELATIONSHIP IN CHIROPRACTIC
CHIROPRACTIC: It is important to acknowledge the difference between the health care specialties of chiropractic, osteopathy and medicine. Chiropractic health care seeks to restore health through natural means without the use of medicine or surgery. This gives the body maximum opportunity to utilize its inherent recuperative powers. The success of the chiropractic doctor’s procedures often depends on environment, underlying causes, physical and spinal conditions. It is important to understand what to expect from chiropractic health care services.
ANALYSIS: A doctor of chiropractic conducts a clinical analysis for the express purpose of determining whether there is evidence of Vertebral Subluxation Syndrome (VSS) or Vertebral Subluxation Complexes (VSC). When such VSS and VSC complexes are found, chiropractic adjustments and ancillary procedures may be given in an attempt to restore spinal integrity. It is the chiropractic premise that spinal alignment allows nerve transmission throughout the body and gives the body an opportunity to use its inherent recuperative powers. Due to the complexities of nature, no doctor can promise you specific results. This depends upon the inherent recuperative powers of the body.
DIAGNOSIS: Although doctors of chiropractic are experts in chiropractic diagnosis, the VSS and VSC, they are not internal medical specialists. Every chiropractic patient should be mindful of his/her own symptoms and should secure other opinions if he/she has any concern as to the nature of his/her total condition. Your doctor of chiropractic may express an opinion as to whether or not you should take this step, but you are responsible for the final decision.
RESULTS: The purpose of chiropractic services is to promote natural health through the reduction of the VSS or VSC. Since there are so many variables, it is difficult to predict the time schedule or efficacy of the chiropractic procedures. Sometimes the response is phenomenal.
In most cases there is a more gradual, but quite satisfactory response. Occasionally, the results are less than expected. Two or more similar conditions may respond differently to the same chiropractic care. Many medical failures find quick relief through chiropractic. In turn, we must admit that conditions which do not respond to chiropractic care may come under the control or be helped through medical science. The fact is that the science of chiropractic and medicine may never be so exact as to provide definite answers to all problems. Both have made great strides in alleviating pain and controlling disease.
Financial Policy: We are committed to providing you with the best possible care. If you have insurance, we are anxious to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and your understanding of our payment policy.
Payment for services is due at the time services are rendered unless payment arrangements have been approved in advance by our staff. We accept cash, checks, Master Card, Visa, American Express, and Discover. All checks should be made out to Wyoming Valley Family Chiropractic Center. We will be happy to process your insurance claim-form for your reimbursement. Any such request must be accompanied by a completed insurance form at each visit. In special instances, we accept assignment of insurance benefits. If we accept assignment of benefits all co-payments and deductibles are due at the time for service. If it turns out there is an unforeseen deductible you will be billed later.
We will gladly discuss your proposed treatment and answer any questions relating to your insurance. You must realize however, that:
We must emphasize that, as chiropractic providers, our relationship is with you, not your insurance companies. While the filing of insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date the service was rendered. We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in management of your account.
If you have any questions about the above information or any uncertainty regarding your insurance coverage, PLEASE don’t hesitate to ask us. We are here to help you.
I understand and agree that (regardless of my insurance status); I am ultimately responsible for the balance of my account for any professional services rendered as per the financial policy. The financial policy is posted in the waiting room, on the back of this form, and a copy will be furnished on request.
MFCC HIPPA POLICY
I also certify that I have been given the opportunity to read MFCC’s HIPPA policy. The policy is posted on the waiting room bulletin board I realize that at any time I can request a copy of the HIPPA policy and may ask for clarification. At this time I fell that I have a full understanding of the policy.
ASSIGNMENT OF BENEFFITS
I hereby instruct and direct above listed Insurance Company (s) to pay by check made out to MFCC. For the professional or medical expense benefits allowed and otherwise payable to me under my current insurance policy as payment toward the total charges for professional services rendered. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above mentioned assignee, and I have agreed to pay, in a current manner any balance of said professional service charges over and above this insurance payment. (1: a photocopy of this assignment shall be considered as effective and valid as the original; 2: I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in my case; 3: I authorize doctor to initiate a complaint to the Insurance Commissioner for any reason on my behalf)
Policies can be found at the following link: Financial, HIPAA, and other policies
Please Read and discuss any question or problems with the doctor BEFORE signing this statement of policy.