The privacy of your medical information is important to us. HIPAA stands for the Health Insurance Portability and Accountability Act and involves the protection of patient information-including the privacy and security of that information. Bexley Chiropractic Clinic will not use or disclose your health information except for the purposes of treatment, payment, and health care operations.*
*Treatment- (includes activites performed by a health care provider or office staff, and other health care professionals who you may be referred to, or your case consulted with.)
*Payment (includes activities involved in determining your eligibility for health plan coverage, billing, and receiving payment.)
*Health Care Operations (includes the necessary administrative and business functions in our office)
You may review Bexley Chiropractic Clinic's "Notice of Privacy Practices" for additional information about the uses and disclosures of information. It is available at the front desk upon request. By signing below, you are authorizing Bexley Chiropractic Clinic to use and disclose the health and medical information for the purposes listed above.
I authorize direct payment to Jeffrey Guindon DC for any insurance benefits otherwise payable to me for the services rendered. I understand that I am responsible for all charges whether or not paid by insurance. I authorize Jeffrey Guindon DC to release all information necessary to secure benefits. I authorize the use of this signature on all insurance claims.
I hereby request and consent to the performance of chiropractic adjustments/manipulations and examination procedures (or on the patient named below, for whom I am legally responsible) by Jeffrey Guindon DC, or any licensed chiropractor who treats me at Bexley Chiropractic Clinic.
I will have an opportunity to discuss the nature and purpose of chiropractic adjustments/manipulations with my chiropractor at Bexley Chiropractic Clinic. I understand that a patient will experience an audible "popping" sound, which is a normal part of treatment. Bexley Chiropractic Clinic performs full spine treatments, which may include areas other than my chief complaint, in an effort to treat the problem.
I understand and am informed that, as is with all practices of medicine, in the practice of chiropractic there are some risks to treatment. The most common complication or complaint is an ache or stiffness at the site of treatment. The probability of a serious injury is extremely rare, and according to research is 1:1,000,000, or about the same risk as being struck by lightning. Although rare, complications also include, but not limited to fractures, disc injuries, dislocations, and stroke. I do not expect the doctor to be able to antipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgement during the course of the procedure which the doctor feels at the time, based upon the facts then known, is in my best interests.
I understand and I am informed that, as is with all healthcare treatments, results are not guaranteed and there in no promise to cure. Accordingly, I understand that all payments for treatments are final, and no refunds will be issued. However, prorated fees for unused, prepaid treatments will be refunded if I wish to cancel the treatment.
I have read, or have had read to me, the above consent. I will also have an opportunity to ask questions about its content, and by signing below I agree to the above named procedures. I intend this consent form to cover the entire course of treatment for my current condition and for any future conditions for which I seek treatment.