I clearly understand that all insurance coverage, whether accident, 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 that they are performing these services are strictly as a convenience to me. The office will provide any necessary reports or required information to aid in insurance reimbursement of services. I understand that insurance carriers may deny my claims and that I am ultimately responsible form any unpaid balances. Any
monies received will be credited to my account.
I hereby agree that the Practice will not be liable for any failure to provide, or delay in providing, services to me in the event that the Practice and its providers are assisting other patient(s) in an emergency or in the event of other circumstances beyond the reasonable control of the Practice. In the event of an Emergency, or a situation in which I could reasonably expect an emergency to arise, I agree to call 911 or visit the nearest emergency room and follow the directions of the emergency personnel.
This serves as notice that as part of our efforts to deliver the most consistent healthcare we can to every patient, we use an electronic healthcare system that enables us to retrieve up to 13 months of prescription history through your insurance carrier.
I understand and agree that chiropractic care, like all forms of health care, while offering considerable benefit may also provide some level of risk. This level of risk is most often very minimal. The types of complications that have been reported secondary to chiropractic care include sprain/strain injuries, irritation of a disc condition, and rarely, fractures, one of the rarest complications associated with chiropractic care, occurring at a rate between one instance per one million to one per two million cervical spine (neck) adjustments may be a vertebral artery injury that could lead to stroke.
I acknowledge that it is the policy of the Practice and its staff to leave a telephone message regarding my medical care with the following options: (Initial each one that you want us to be able to use for leaving you a telephone message). This will remain in effect until you rescind it in writing.
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