Informed Consent for Chiropractic Care

Transcription

1 Informed Consent for Chiropractic Care When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both of us to be working toward the same objective. This will prevent any confusion or disappointment. You have the right, as a patient, to be informed about the condition of your health and the recommended care and treatment to be provided so that you may make the decision whether to choose chiropractic care after being advised of the known benefits, risks and alternatives. Chiropractors do not medically diagnose or treat any specific disease or condition. Chiropractors provide a unique service that other healthcare providers do not offer: the detection and correction of vertebral subluxations.. A vertebral subluxation occurs when one or more of the 24 vertebra in the spinal column become misaligned and/or do not move properly. This causes alteration of nerve function and interference to the nervous system. This interference may result in pain and dysfunction or may be asymptomatic for years. Subluxations and misalignments in the joints of the body can be corrected or reduced by a chiropractic adjustment. Traditionally, chiropractic adjustments have been done by hand (i.e., manual therapy). This office primarily follows the Atlas Orthogonal procedure, which uses a table-mounted instrument. This provides a gentle, precise, and low-force program of upper cervical chiropractic care. We also use a hand-held instrument called the Activator to address the spine and joints of the extremities as required. Additional procedures such as physiotherapy and/or rehabilitative procedures may also be included as part of your care plan. Very occasionally, we may use a manual adjusting technique to address subluxations of the thoracic or lumbar spine, or the joints of the extremities. While rare, the risks associated with manual therapy are as follows: a) There have been reported cases of rib fractures and muscle and ligament strains or sprains as a result of forceful manual therapy techniques; b) There have been reported cases of stroke associated with many common neck movements including adjustment of the upper cervical spine. However, present medical and scientific evidence does not establish a definite cause and effect relationship between manual upper cervical spine adjustment and the occurrence of stroke; and, c) There have been reported cases of disc injuries following cervical and lumbar spinal adjustment although no scientific study has ever demonstrated such injuries are caused, or may be caused, by spinal adjustments. Alternatives to chiropractic care for certain conditions include physical therapy, medication and/or surgery. Chiropractic treatments, including spinal adjustment, have been the subject of government reports and multi-disciplinary studies conducted over many years and have been demonstrated to be effective treatment for many cervical and back conditions. The risk of injuries or complications from chiropractic care is substantially lower than that associated with many other treatments, medications, and medical procedures given for the same symptoms.

2 The benefits, risks and alternatives of chiropractic care have been explained to me to my satisfaction. I have read and fully understand the above statements and therefore accept chiropractic care on this basis. Patient Name (Print) Consent to evaluate and adjust a minor child: I, (print) being the parent or legal guardian of (print) have read and fully understand the above Informed Consent and hereby grant permission for my child to receive chiropractic care.

3 Acknowledgement of Financial Responsibility Your insurance policy is a contract between you and your carrier. While many policies reimburse for at least some chiropractic care, coverage varies from policy to policy and it changes constantly. My goal is to help you get well and stay well. Sometimes this goal is at odds with the profit motives of an insurance company. This is frustrating for them, for me, and for you. I am not enrolled as a provider with any insurance company (except Medicare) and I do not accept assignment of benefits from any insurance company (including Medicare). This means that payment for all services is expected at the time of service. If you are a Medicare subscriber, our office will file the necessary claim forms for you. If your contract is with a different insurance carrier, we will supply you with the documentation you will need for filing your claim. Reimbursement will come directly to you. I will provide you with the best chiropractic care I can. I will do that as efficiently and as costeffectively as I can. I will explain the purpose of every procedure. Some services I recommend may not be covered by your insurance. We will discuss your options, and the choice is always yours. Cancellation Policy: Accidents happen! but please do your very best to let us know within 24 hours if you will be unable to honor your scheduled appointment. Please note that you will be charged $40 for a missed appointment without timely notice. Returned Check Policy: The $35 bank fee charged for returned checks will be passed on to you. I understand that payment for all services will be due at the time services are rendered. Should this account be referred to an agency or an attorney for collection (50 days after date of service), I understand that I will be responsible for all collection costs, attorney fees and court costs. I accept financial responsibility for my care. I instruct this office to deliver the care that, in their judgment, can best serve me in the restoration and maintenance of my health. Patient Name (Print)

4 Protected Patient Health Information: Privacy Practice & Acknowledgement THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW TO GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. is required, by law, to maintain the privacy and confidentiality of your protected health care information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health care information. Protected health care information is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health and related health care services. Disclosures of Your Health Care Information We may disclose your health care information to other healthcare professionals within or outside our practice for the purpose of treatment, payment or healthcare operations. Treatment: This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. Payment: We may disclose your health information to your insurance provider, as needed, to help you obtain payment for your health care services. Healthcare Operations: We may use or disclose, as needed, information about you in order to support the business activities of this practice. For example, we may use a sign-in sheet at the registration desk where you will be asked to sign your name, and we may also call you by name in the waiting room when the chiropractor is ready to see you. Moreover, within our office policy, we may: Send you recall cards, special announcements and birthday wishes. Call your home or business to advise you of an appointment and/or need to be seen. No personal health information will be disclosed in any messages other than the date and time of your scheduled appointment along with a request to call our office if you need to cancel or reschedule your appointment. If any part of our office policy is not agreeable to you, please inform us immediately. We will honor your requests and make a record of such in your file immediately. Workers Compensation: We may disclose your health information as necessary to comply with State Workers Compensation Laws. Emergencies: We may disclose your health information to notify or assist in notifying a family member, or another person responsible for your care about your medical condition in the event of an emergency. You must designate the person(s) to whom you authorize the release of such information. Public Health: As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling communicable diseases; injury or disability, reporting abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications, and reporting disease or infection exposure. Research: We may disclose your health information to researchers conducting research that has been approved by an Institutional Review Board. Judicial and Administrative Proceedings: We may disclose your health information in the course of any administrative or judicial proceeding. Law Enforcement: We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena, and other law enforcement purposes. Public Safety: It may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health and safety of a particular person or the general public. Specialized Government Agencies: We may disclose your health information for military, national security, prisoner and government benefits purposes. Deceased Persons and Organ Donation: We may disclose your health information to coroners, medical examiners and/or organizations involved in procuring, banking or transplanting organs and tissues.

5 Your Rights The following is a statement of your rights with respect to your Protected Health Care Information. You have the right to inspect and copy your protected health care information. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes, information compiled in the reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. You have the right to request a restriction of your protected health care information. Your request must state the specific restriction requested and to whom you want the restriction to apply. Please be advised, however, that your physician is not required to agree to a restriction that you request. You have the right to request to receive confidential communications from our office by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request. You have the right to request that amend your protected care health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health care information. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. Complaints Complaints about your Privacy rights, or how has handled your health information should be directed to Dr. Margaret Winters by calling this office at. If you are not satisfied with the manner in which this office handles your complaint, you may submit a formal complaint to: Dept. of Health and Human Services, Office of Civil Rights 200 Independence Ave., SW Room 509F HHH Building Washington, DC This notice was published and becomes effective on or before November 1, Person(s) to whom I authorize release of my healthcare information: By means of my signature, I provide with my authorization and consent to use and disclose my protected health care information for the purposes described in this Notice of Privacy Practices: Patient s Name (print): Patient s : : You may revoke this authorization, at any time in writing, except to the extent that your physician or the physician s practice has taken an action relying on the use or disclosure indicated in the authorization.