HIPAA Privacy Rule of Patient

Authorization Agreement Authorization for the Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.508(a))

I understand that as part of my healthcare, this Practice originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves as:

  • a basis for planning my care and treatment;
  • a means of communication among the health professionals who may contribute to my healthcare;
  • a source of information for applying my diagnosis and surgical information to my bill;
  • a means by which a third-party payer can verify that services billed were actually provided;
  • a tool for routine health care operations such as assessing quality and reviewing the competence of healthcare professionals.

I have been provided with a copy of the Notice of Privacy Practices that provides a more complete description of information uses and disclosures.

I understand that as part of my care and treatment it may be necessary to provide my Protected Health Information to another covered entity. I have the right to review this Practice’s notice prior to signing this authorization. I authorize the disclosure of my Protected Health Information as specified below for the purposes and to the parties designated by me.

Privacy Rule of Patient Consent Agreement

Consent to the Use and Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.506(a))

I understand that:

  • I have the right to review this Practice’s Notice of Information practices prior to signing this consent;
  • that this Practice reserves the right to change the notice and practices and that prior to implementation will mail a copy of any notice to the address I’ve provided, if requested;
  • I have the right to object to the use of my health information for directory purposes;
  • I have the right to request restrictions as to how my Protected Health Information may be used or disclosed to carry out treatment, payment, or healthcare operations, and that this Practice is not
    required by law to agree to the restrictions requested;
  • I may revoke this consent in writing at any time, except to the extent that this Practice has already taken action in reliance thereon.

Patient Consent for Use and Disclosure of Protected Health Information

  • I hereby give my consent for Advanced Spine & Posture to use and disclose my protected health information (PHI) to perform treatment, payment and health care operations (TPO).
  • With this consent, the Practice may call me or email me to my home or other alternative location and leave a message by voice, email or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and anything pertaining to my clinical care, including laboratory test results.
  • With this consent, the Practice may mail to my home or other alternative location any items that assist the practice in performing TPO, such as appointment reminder cards, patient statements and anything pertaining to my clinical care.
  • By signing this form, I am consenting to allow the Practice to use and disclose my PHI to carry out TPO.

Consent for Emergency Contact: I hereby authorize the release of my health information to my designated emergency contact to be used by Advanced Spine & Posture in any case of an emergency.

Signature of Patient or Legal Representative Witness:

Insurance and Payment Policy Consent

By signing below, I verify that, I clearly understand that all insurance coverage, whether accident, auto, work related, or general coverage is an arrangement between my insurance carrier and myself. If this office chooses to bill any services to my insurance carrier this is done strictly as a convenience and courtesy for me. This office may provide any necessary reports subject to reasonable service fees to aid in insurance reimbursement of services, but I understand that insurance carriers may deny my claims and that I am ultimately responsible for any unpaid balances. Any money received will be credited to my account. I understand there could be some services that my insurance company does not cover, if this is the case I am willing to pay for these services.

I also understand that I will be charged $25 for any and all scheduled appointments that are missed without contacting the office in advance. This missed visit fee WILL NOT be
covered by insurance and must be paid prior to the next scheduled visit.

I understand my credit/debit card information will be stored securely by a third party in compliance with PCI laws. Advanced Spine & Posture team members will only have access to the last 4 digits of my card number.

I acknowledge I am responsible for updating my information in the event the card expires or becomes invalid. In the event my card is declined, I agree that I am responsible for payment of the full amount immediately.

Consent to Treatment

I authorize and agree to allow the physician, nurse practitioner, physician assistant, physical therapist, chiropractor, and/or assistants(s) to the use of physical examinations, x-rays, structural and/or functional physiotherapy, spinal adjustments, rehabilitative exercises (in office and at home), traction, injections and other methods for the sole purpose of postural and structural improvement in biomechanical and related neurological function.

The healthcare providers and/or assistants will not be held responsible for any health conditions or diagnoses which are pre-existing, given by another health care practitioner, or are not related to the spinal structural conditions diagnosed at this clinic. I also clearly understand that if I do not follow the healthcare providers and/or assistants specific recommendations at this clinic that I will not receive the full benefit from this program, and that if I terminate my care prematurely that all fees incurred will be due and payable at that time. Any discounts are at the discretion of Advanced Spine & Posture and failure to keep your treatment plan agreement may result in full fees being applied. I authorize the assignment of all insurance benefits to be directed to Advanced Spine & Posture for all services rendered.

As a part of the analysis, examination and treatment of my condition(s) I am consenting to the following procedures: Spinal/Joint Mobilizations, Spinal Adjustment/Manipulative Therapy, Range of motion testing, Muscle strength testing, Radiographic Study/ X-ray, Orthopedic examination, Postural Analysis, Physical examination, Vital signs, Neurological Examination, Traction, Various Therapeutic Exercises, Manual therapy, Cryotherapy(ice), Heat Therapy, Electrical Stimulation, Taping techniques, Dry Needling, Instrument Assisted Soft Tissue Mobilization (IASTM), Cupping Therapy techniques, muscle and/or joint palpation (examining the body using touch), at home exercise program, trigger point injections and/or any other services recommended by the providers. I authorize/understand that Advanced Spine & Posture will bill my insurance, as a courtesy in an attempt to help cover the cost of the treatments provided. I allow Advanced Spine & Posture to file my insurance in an attempt to pay for the care I receive.

I hereby give my permission for Advanced Spine & Posture to give me Medical, Physical Therapy and/or Chiropractic treatment.

I understand that:

  • Advanced Spine & Posture will have to send my medical record information to my insurance company.
  • I must pay my share of the costs.
  • I must pay for the cost of these services if my insurance does not pay or I do not have insurance.
  • I am responsible for all fees incurred for the services provided, and agree to ensure full payment of all charges.

I understand:

  • I have the right to refuse any procedure or treatment.
  • I have the right to discuss all treatments with my provider(s).

The Nature & Risk Care

The Nature of the Adjustment/Manipulation

One of the primary treatments used by a Doctor of Chiropractic is the spinal adjustment or spinal manipulative therapy. We will use this type of procedure with you. We may use our hands or a mechanical instrument upon your body in such a way as to move your joints. This may cause an audible “pop” or “click” much like one experiences from “popping” knuckles. You may feel a sense of movement.

The material risks inherent in spinal and/or joint adjustment
As with any healthcare procedure, there are certain complications which may arise with adjustment/ manipulation and therapy. These complications include but are not limited to: fracture, disc injury, dislocation, muscle strain, cervical myelopathy, costovertebral strains and separations. Some types of adjustment/manipulation of the neck have been associated with injuries to the arteries of the neck leading to or contributing to serious complications including stroke. Some patients will feel some stiffness and soreness following the first few days of treatment. This is similar to the soreness associated with working out and the “lactic acid “response. We will make every reasonable effort during the examination to screen for contradictions to care; however, if you have a condition that would otherwise not come to our attention, it is your responsibility to inform us.

The Probability of those risks occurring
Fractures are rare occurrences and generally the result of an underlying weakness of the bone which will be checked for during your history, examination and on x-ray. Stroke has been the subject of tremendous disagreement. The incidences of stroke are exceedingly rare and are estimated to occur between one in one million to one in five million cervical adjustments. The other complications are also described as generally rare.

The availability and nature of other treatment options
Other treatment options for your condition may include: Self administered, OTC treatments/medications, Medications and prescription drugs, Hospitalization and Surgical procedures

The risks and dangers attendant to remaining untreated
Remaining untreated may allow the formation of joint adhesions, and reduced mobility which may lead to a pain reaction and further reduced mobility. Over time this process may complicate treatment making it more difficult and less effective the longer care is postponed.

Trigger Point Injections
Trigger Point Injections (TPI) are used to treat extremely painful and tender areas of muscle. A small needle is inserted into the trigger point and a local anesthetic (e.g. lidocaine, procaine, bupivacaine) is injected. This procedure inactivates the trigger point to alleviate pain.

I understand and accept the most likely risks and complications of trigger point injections, which include but are not limited to:

  • Pneumothorax/Collapsed Lung
  • Infection
  • Needle Breakage
  • Numbness
  • Trauma to Nerves
  • Vasovagal Reaction (fainting)
  • Soft Tissue Swelling, Bruising Or Hematoma

Physical Therapy

Physical Therapy is used to treat mobility, strength, and functional deficits. It can be utilized during pre/post surgical rehabilitation, acute injury recovery, to enhance the musculoskeletal system, improve balance, and provide support for activities of daily living. Physical fitness, overall health, and functional performance may also be improved

Risks may include: temporary muscle soreness (DOMS), fatigue, strain, worsening of the pre-existing conditions, increased metabolism, falls, and/or lactic acid production.