CURRENT CONDITION(S)

REVIEW OF SYSTEMS

LIFESTYLE

MOTORVEHICLE ACCIDENT INFORMATION

Functional Rating Index

For Neck and/or Back Problems only

In order to properly assess your condition, we must understand how much your neck and/or back problems have affected your ability to manage everyday activities, please choose the number which most closely describes your condition right now.

OFFICE POLICY

Welcome to Back in Line Health Care. We are honored that you chose to use our services to get back on the road to health as soon as possible and we will do whatever we can to help. Please take a moment to read and sign the following patient agreement. If you have any questions regarding our payment or treatment policies, please do not hesitate to ask.

Our Payment Policy:

Our payment policy is to collect the following fees at time of service, for initial visits using personal medical insurance.

                Medicare: $80 deposit

                All other insurance: $120 deposit

                Non-insured: $155-$175 depending on services provided.

Cancellation & Missed Appointment Policy:

If you cancel your appointment less than 24 hours before it is scheduled to take place or fail to show for your scheduled appointment, you will be subject to a $25 cancellation fee.

If You Have Insurance:

If you have insurance, Back in Line Health Care will submit appropriate paperwork required for your claim to be processed to your insurance company. Any covered but unpaid services are your responsibility.

By signing below, you also acknowledge that it is your responsibility to obtain insurance coverage information and you will not hold Back in Line Health Care liable for any discrepancies in information supplied by the Insurance Company.

For Medicare Patients:

Medicare plans only pay for an adjustment and an exam must be performed so treatment may start, so a deposit of $80 is required on your fist visit.

Back in Line Health Care provides other services that are not covered and beneficial to care, so an ABN is required with option 2. checked, to get the time-of-service discount.

Accident Cases:

Back in Line Health Care only takes motor vehicle cases where the involved party has PIP or medical coverage that covers service provided. If care exceeds your benefits and an attorney is involved Back in Line Health Care requires documentation from the attorney stating all fees accumulated will be paid in full directly by the attorney once the cases is settled.

Injuries At Work:

If you were injured on the job and your treatment is covered by workers’ compensation, the Clinic will bill the workers’ compensation department and no payment is required.

Late Fees:

Any treatment bill remaining after (60) days will bear interest at the rate of 12% until paid. If Back in Line Health Care must hire an attorney or collection agency to collect past due bills, you must reimburse the clinic for any attorney fees, court costs and collection charges spent in collecting the bill.

Authorization To Release Information:

You give Back in Line Health Care permission to release information about your physical condition to any insurance company or attorney to process your bills for payment.

PROTECTIVE HEALTH INFORMATION

I consent to the use or disclosure of my protected health information by Back in Line Health Care for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of Back in Care Health Care.

I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or health care operations of the practice.  Back in Line Health Care is not required to agree to the restrictions that I may request.  However, If Back in Line Health Care agrees to a restriction that I request, the restriction is binding.

I have the right to revoke this consent, in writing, at any time, except to the extent that Back in Line Health Care has taken action in reliance on this consent.

My “protected health information” means health information, including my demographic information, collected from me and created or received by my physician, Aaron Herbert, DC., a health plan, my employer or a health care clearinghouse.  This protected health information relates to my past, present or future physical or mental health condition and identifies me, or there is a reasonable basis to believe the information may identify me.

I understand I have a right to review Back in Line Health Care’s Notice of Privacy Practices prior to signing this document.

The Back in Line Health Care’s Notice of Privacy Practices has been provided to me.

The Notice of Privacy Practices described the type of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Back in Line Health Care.

This Notice of Privacy Practices also describes my rights and the duties of Aaron Herbert, DC. with respect to my protected health information.

Aaron Herbert, DC. reserves the right to change the privacy practices that are described in the Notice of Privacy Practices.

I may obtain a revised notice of privacy practices by calling Back in Line Health Care (Aaron Herbert, DC) and requesting a revised copy be sent via email, mail or asking for one at my next appointment.

PATIENT PRIVACY SUMMARY

We are committed to preserving the privacy of your personal health information.  In fact, we are required by law to protect the privacy of your medical information and to provide you with notice describing:

HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND

DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION.

We are required by law to have your written consent before we use or disclose to others your medical information for the purposes of providing or arranging for your health care, the payment for or reimbursement of the care that we provide to you, and related administrative activities supporting your treatment.

We may be required or permitted by certain laws to use and disclose your medical information for other purposes without your consent or authorization.

As our patient, you have important rights relating to inspecting and copying your medical information that we may maintain, amending or correcting that information, obtaining an accounting of our disclosures of your medical information, requesting that we communicate with you confidentially, requesting that we restrict certain uses and disclosures of your health information, and complaining if you think your rights have been violated.

We have available a detailed Notice of Privacy Practice which fully explains your rights and our obligations under the law.  We may revise our Notice from time to time.  The effective date at the top right hand side of this page indicates the date of the most current Notice in effect.

You have the right to receive a copy of our most current Notice in effect.  If you have not yet received a copy of our current Notice, please ask at the front desk and we will provide you with a copy.

If you have any questions, concerns or complaints about the Notice or your medical information please contact Back in Line Health Care 360-859-3867

CONSENT TO TREAT

I hereby request and consent to treatment by Dr. Aaron Herbert and/or other licensed professionals, who may practice with, or are employed by Dr. Herbert.

1.       Chiropractic care is the science, philosophy and art of locating and correcting spinal subluxations (misalignments) and, as such is oriented toward improvement of spinal function relative to range-of-motion, muscular and neurological aspects. Extremities may also be treated as related to spinal function. There has been no promise, implied or otherwise, of a cure for any symptom, disease or condition as a result of treatment at this clinic.

2.       I understand that the chiropractor or massage therapist will use their hands or a mechanical device upon my body to locate and treat involved areas. They may apply pressure on certain spots in my muscles to the point I can tolerate. I am always to communicate with the doctor/massage therapist to let them know if any procedure is painful or in any way uncomfortable for me.

3.       It is my intention to rely on the doctor/therapist to exercise professional judgment during the course of any procedures/treatment in which they feel at the time to be in my best interest.

4.       Neither the practice of chiropractic or medicine is an exact science, but relies upon information related by the patient, information gathered during the examination, and the doctor's interpretation thereof, as well as the doctors’ judgment and expertise in working with like cases.

5.       It is not reasonable to expect the doctor/therapist to be able to anticipate, or explain, all possible risks and complications of a given procedure on any particular visit. I understand that if I have questions or concerns, I must ask.

6.       An undesirable result or side effect does not necessarily indicate an error in judgment or an improper procedure. The doctor may recommend altering my activities of daily living and/or recommend further diagnostic testing or medical referral. Noncompliance with the doctor's recommendations could be detrimental to my health.

7.        As with any health care procedure, there are certain complications that may arise during chiropractic treatment. Those complications include burns, sprains/strains, dislocations, fractures, disc injuries, or cerebral-vascular accidents (strokes). These complications are rare occurrences.

8.       Some very effective chiropractic soft tissue treatment and/or massage techniques require exposure of the skin in the areas being treated. A proper gown and/or cover up will always be provided. However, due to individual levels of personal modesty, if you feel at all uncomfortable, please immediately tell the doctor/therapist or assistant. A different treatment technique will be used.

9.       Generally, chiropractic or massage treatment are a safe and cost-effective conservative treatment for many musculoskeletal conditions and have been documented with high level of patient satisfaction toward treatment and outcome.  However, there are other treatment options available to you such as medical, drugs and sometimes surgery.

I have read the above consent, or have had it read to me, and have had the opportunity to ask questions and receive answers. I am comfortable with the information provided and consent to chiropractic treatment and management on that basis.xt

PATIENT RECORDS OF DISCLOSURES

I wish to be contact in the following manner (check all that apply)