Personal Information

IN THE EVENT OF AN EMERGENCY

IMPORTANT: Please give the office your insurance identification cards and driver's license for verification purposes. Thank you!

ALL INFORMATION WILL REMAIN CONFIDENTIAL

 

I understand and agree that health and accident policies are an agreement between an insurance carrier and myself. Furthermore, I understand that Associated Chiropractic will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to Associated Chiropractic will be credited to my account upon receipt. However, I clearly understand that if I suspend or terminate care and treatment, any fees for professional services rendered to me will be immediately due and payable.

Health Information

Understanding your pain is important to us. This scale helps us to understand and to treat your pain. Using the numbers on this pain scale, please enter the appropriate answer for each body region listed below.

 

0	1-2	3-4	5-6	7-8	9-10
No Pain	Sore Ache	Mild Pain	Moderate Pain	Severe Pain	Worst Pain Imaginable

 

Please check all symptoms that you currently have or have had.

Office Policies

BILLING & FINANCIAL:

• Although you may carry health insurance coverage, please realize that YOU are fully responsible for all bills incurred at this clinic. You are responsible for any unpaid deductibles and your per-visit co-payment/coinsurance. If you have not paid the required amount or an outstanding balance exists after insurance processing of your claims, you will receive a monthly statement reflecting the patient balance as of the statement date. We are happy to provide you with your current account balance at any time upon request. As a new patient, your examination charge must be paid in full with the exception of a few insurance carriers.
• Our office will submit your claims to your insurance carrier after receiving all necessary information from you and your carrier. Some insurance companies mail doctor's reimbursements directly to the patient. Other companies will send them directly to the doctor's office. Upon verification of your specific insurance policy coverage, you will be notified how your particular carrier handles the payment of your claims.
• Legitimate Auto accidents or Worker Compensation Cases claims will be billed according to PA Law. There is no financial responsibility to you but it is your responsibility to get us all pertinent information, including accident/incident reports, prior medical treatment information, and records. For Auto Accident Claims: it is your responsibility to complete any and all information necessary sent to you by your auto insurance carrier in order for our office to receive claim reimbursement or you will be billed directly. If represented by an attorney then a protection offees must be signed and accepted by both you and your attorney.
• Your signature at the end of this form indicates that you understand these billing policies and that you are personally responsible for all services and products supplied to you by Allentown Health Services (AHS), and that payment is due upon receipt. You further agree to pay reasonable processing and collection costs, reasonable attorney's fee, and interest in the event that you fail to abide by these provisions.

SCHEDULING:

We operate on a scheduled appointment basis to ensure proper care and courtesy of our patients time. Please make sure to keep your scheduled appointments and honor "your time'. A 24-hour advance notice is required for any canceled or missed appointments. We understand that emergencies arise and will grant one missed appointment without prior notice. Subsequent occurrences with a failure to provide the 24-hour notice will result in a $20.00 charge to be added to your account balance. This charge is the patient responsibility and is not billable to any third party carriers.

A note to our patients with children: We ask you to explain to your children the importance of the patient care that we are providing for you and everyone else. We ask that your children remain in the reception room during your visits. This will enable you and our other patients to receive care fully undisturbed. Please restrict your children from playing with the water cooler, rough housing and loud behavior.

We are very pleased to participate in your healthcare, and have set aside time for your appointment. We understand that sometimes it is necessary to cancel or change an appointment. In consideration of the others who need care, we ask that if you are unable to keep an appointment with our office, that you please observe our cancellation policy which follows:

Our office requires at least 6 hour notice for all appointment cancellations. If you are unable to provide a 6 hour notice, you will be billed a $30.00 charge to your credit card on file for scheduled chiropractic appointments.

SECURITY CAMERA ACKNOWLEDGEMENT:

In an effort to assist our staff and doctors in providing our patients with the best possible care and service, AND to provide extra security for all employees, patients and our office buildings, we have installed security cameras throughout the premises (excluding the bathroom, reception and x-ray rooms). Any video/audio recordings will be utilized to assist our staff with both security and for educational training purposes. Your signature below indicates that you have been notified and accept our policy that this equipment may be in use during your office visit. Thank you for your understanding and cooperation and for allowing us to provide this valuable service.

“OPEN ADJUSTING" ENVIRONMENT:

It is the practice of Associated Chiropractic to provide chiropractic care in an "open adjusting” environment. Patients are within sight of one another and some ongoing routine details of care are discussed within earshot of other patients and staff. This environment is used for ongoing care and is NOT the environment used for taking patient histories, performing examinations, or presenting reports of findings. These particular procedures are completed in a private, confidential setting.

We are requesting this signature authorization from you due to various interpretations under federal law with respect to what is known as “incidental disclosures” of health information. It is our view that the kinds of matters related in an “open adjusting environment are incidental matters, and in the event you or someone would not agree with us we are providing this disclosure.

The use of this format is intended to make your experience with our office more efficient and productive as well as to enhance your access to quality health information. If you choose not to be adjusted in an "open adjusting” environment other arrangements will be made for you. Your decision will have no adverse effect on your care from Associated Chiropractic or on your relationship with our staff.

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES:

I acknowledge that I was provided a copy of the Notice of Privacy Practices as set forth in the HIPAA Act of 1996 and that I have read (or had the opportunity to read if I so choose) and understood the Privacy Notice.

NOTE: You may revoke this authorization at any time. Revocation may be accomplished by advising us in writing of your desire to withdraw your authorization. Please allow a reasonable processing time for the change in our procedures to be completed

Effective Date: 09/23/2013

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

If you have any questions about this notice, please contact Dr. Joseph A. Perelli.

 

OUR OBLIGATIONS:

We are required by law to:

• Maintain the privacy of protected health information
• Give you this notice of our legal duties and privacy practices regarding health information about you
• Follow the terms of our notice that is currently in effect

 

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION:

The following describes the ways we may use and disclose health information that identifies you ("Health Information"). Except for the purposes described below, we will use and disclose Health Information only with your written permission. You may revoke such permission at any time by writing to our practice Privacy Officer.

For Treatment. We may use and disclose Health Information for your treatment and to provide you with treatment-related health care services. For example, we may disclose Health Information to doctors, nurses, technicians, or other personnel, including people outside our office, who are involved in your medical care and need the information to provide you with medical care.

For Payment. We may use and disclose Health Information so that we or others may bill and receive payment from you, an insurance company or a third party for the treatment and services you received. For example, we may give your health plan information about you so that they will pay for your treatment.

For Health Care Operations. We may use and disclose Health Information for health care operations purposes. These uses and disclosures are necessary to make sure that all of our patients receive quality care and to operate and manage our office. For example, we may use and disclose information to make sure the obstetrical or gynecological care you receive is of the highest quality. We also may share information with other entities that have a relationship with you (for example, your health plan) for their health care operation activities.

Appointment Reminders, Treatment Alternatives and Health Related Benefits and Services. We may use and disclose Health Information to contact you to remind you that you have an appointment with us. We also may use and disclose Health Information to tell you about treatment alternatives or health-related benefits and services that may be of interest to уou.

Individuals involved in Your Care or Payment for Your Care. When appropriate, we may share Health Information with a person who is involved in your medical care or payment for your care, such as your family or a close friend. We also may notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort.

Research. Under certain circumstances, We may use and disclose Health Information for research. For example, a research project may involve comparing the health of patients who received one treatment to those who received another, for the same condition. Before we use or disclose Health Information for research, the project will go through a special approval process. Even without special approval, We may permit researchers to look at records to help them identify patients who may be included in their research project or for other similar purposes, as long as they do not remove or take a copy of any Health Information.

 

SPECIAL SITUATIONS:

As Required by Law. We will disclose Health Information when required to do so by international, federal, state or local law.

To Avert a Serious Threat to Health or Safety. We may use and disclose Health Information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Disclosures, however, will be made only to someone who may be able to help prevent the threat.

Business Associates. We may disclose Health Information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, We may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

Organ and Tissue Donation. If you are an organ donor, we may use or release Health Information to organizations that handle organ procurement or other entities engaged in procurement, banking or transportation of organs, eyes or tissues to facilitate organ, eye or tissue donation and transplantation.

Military and Veterans. If you are a member of the armed forces, we may release Health Information as required by military command authorities. We also may release Health Information to the appropriate foreign military authority if you are a member of a foreign military.

Workers' Compensation. We may release Health Information for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks. We may disclose Health Information for public health activities. These activities generally include disclosures to prevent or control disease, injury or disability, report births and deaths; report child abuse or neglect, report reactions to medications or problems with products; notify people of recalls of products they may be using; a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and the appropriate government authority if We believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities. We may disclose Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Data Breach Notification Purposes. We may use or disclose your Protected Health Information to provide legally required notices of unauthorized access to or disclosure of your health information.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose Health Information in response to a court or administrative order. We also may disclose Health Information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement. We may release Health Information if asked by a law enforcement official if the information is: (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a crime even if, under certain very limited circumstances, We are unable to obtain the person's agreement; (4) about a death we believe may be the result of criminal conduct; (5) about criminal conduct on our premises, and (6) in an emergency to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors. We may release Health Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We also may release Health Information to funeral directors as necessary for their duties.

National Security and Intelligence Activities. We may release Health Information to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law.

Protective Services for the President and Others. We may disclose Health Information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or to conduct special investigations.



Inmates or Individuals in Custody. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release Health Information to the correctional institution or law enforcement official. This release would be if necessary: (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others, or (3) the safety and security of the correctional institution.

 

USES AND DISCLOSURES THAT REQUIRE US TO GIVE YOU AN OPPORTUNITY TO OBJECT AND OPT:

Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your Protected Health Information that directly relates to that person's involvement in your health care. If you are unable to agree or object to Such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.

Disaster Relief. We may disclose your Protected Health Information to disaster relief organizations that seek your Protected Health Information to coordinate your care, or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we practically can do so.

 

YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR OTHER USES AND DISCLOSURES:

The following uses and disclosures of your Protected Health Information will be made only with your written authorization:

1. Uses and disclosures of Protected Health Information for marketing purposes;

and

2. Disclosures that constitute a sale of your Protected Health Information

Other uses and disclosures of Protected Health Information not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you do give us an authorization, you may revoke it at any time by submitting a written revocation to our Privacy Officer and we will no longer disclose Protected Health Information under the authorization. But disclosure that We made in reliance on your authorization before you revoked it will not be affected by the revocation.

 

YOUR RIGHTS:

You have the following rights regarding Health Information we have about you:

Right to Inspect and Copy. You have a right to inspect and copy Health Information that may be used to make decisions about your care or payment for your care. This includes medical and billing records, other than psychotherapy notes. To inspect and copy this Health Information, you must make your request, in writing, to Associated Chiropractic, HIPPA Compliance Dept., 656 5th St., Whitehall PA 18052. We have up to 30 days to make your Protected Health Information available to you and We may charge you a reasonable fee for the costs of copying, mailing or other supplies associated with your request. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state or federal needs-based benefit program. We may deny your request in certain limited circumstances. If we do deny your request, you have the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request, and we will comply with the outcome of the review.

Right to an Electronic Copy of Electronic Medical Records. If your Protected Health information is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your Protected Health Information in the form or format you request, if it is readily producible in such form or format. If the Protected Health Information is not readily producible in the form or format you request your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.

Right to Get Notice of a Breach. You have the right to be notified upon a breach of any of your unsecured Protected Health Information.

Right to Amend. If you feel that Health Information we have is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for Our office. To request an amendment, you must make your request, in writing, to Associated Chiropractic, HIPPA Compliance Dept., 656 5th St., Whitehall ΡΑ 18052.

Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures we made of Health Information for purposes other than treatment, payment and health care operations or for which you provided Written authorization. To request an accounting of disclosures, you must make your request, in Writing, to Associated Chiropractic, HIPPA Compliance Dept., 656 5th St., Whitehall PA 18052.

Right to Request Restrictions. You have the right to request a restriction or limitation on the Health Information we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the Health Information We disclose to someone involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not share information about a particular diagnosis or treatment with your spouse. To request a restriction, you must make your request, in Writing, to Associated Chiropractic, HIPPA Compliance Dept., 656 5th St., Whitehall PA 18052. We are not required to agree to your request unless you are asking us to restrict the use and disclosure of your Protected Health Information to a health plan for payment or healthcare operation purposes and such information you wish to restrict pertains solely to a healthcare item or service for which you have paid us "out-of-pocket" in full. If We agree, We will comply with your request unless the information is needed to provide you with emergency treatment.

Out-of-Pocket-Payments. If you paid out-of-pocket (or in other Words, you have requested that we not bill your health plan) in full for a specific item or service, you have the right to ask that your Protected Health Information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.

Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain Way or at a certain location. For example, you can ask that we only contact you by mail or at Work. To request confidential communications, you must make your request, in writing, to Associated Chiropractic, HIPPA Compliance Dept., 656 5th St., Whitehall PA 18052. Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper Copy of this notice. You may obtain a copy of this notice at our web site, www.associatedchiropractic.com. To obtain a paper copy of this notice send the request to: Associated Chiropractic, HIPPA Compliance Dept., 656 5th St., Whitehall PA 18052.

 

CHANGES TO THIS NOTICE:

We reserve the right to change this notice and make the new notice apply to Health Information We already have as well as any information we receive in the future. We will post a copy of our current notice at our office. The notice will contain the effective date on the first page, in the top right-hand corner.

 

COMPLAINTS:

If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact Associated Chiropractic, HIPPA Compliance Dept., 656 5th St., Whitehall PA 18052. All complaints must be made in writing. You will not be penalized for filing a complaint.

**We appreciate your compliance with our Office Policies. If we can better serve you, please let us know.**

NOTICE: You are required to sign and date these documents again once you are in our office for your visit.

Chiropractic Informed Consent To Treat

To the patient:

Please read this entire document prior to signing it. It is important that you understand the infromation contained in this document. If anything is unclear, please ask questions before you sign.

 

The nature of the chiropractic adjustment:

One treament I use as a Doctor of Chiropractic is spinal manipulative therapy. I will use that procedure to treat you. I may use my hands or a mechanical instrument upon your body in such a way as to move your joints. That may cause an audible "pop" or "click," much as you have experienced when you "crack" your knuckles. You may feel a sense of movement.

 

Analysis / Examination / Treatment:

As a part of the analysis, examination, and treatment, you are consenting to the chiropractic procedures.

 

The material risks inherent in chiropractic treatment:

As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation and therapy. These complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, cervical myelopathy, costovertebral strains and separations, and burns. Some types of manipulation of teh neck have been associated with injuries to the arteries in 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. I will make every reasonable effort during the examination to screen for contraindications to care; however, if you have a condition that would otherwise not come to my attention, it is your responsibilty to inform me.

 

The probability of those risks occurring:

Fractures are rare occurrences and generally result from some underlying weakness of the bone which I check for during the taking of your history and during examination and 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 and one in five million cervical adjustments. The other complications are also generally described as rare.

 

The availability and nature of other treatment options:

Other treatment options for your condition may include:

• Self-administered, over-the-counter analgesics and rest
• Medical care and prescription drugs such as anti-inflammatory, muscle relaxants and pain-killers
• Hospitalization
• Surgery

If you chose to use one of the above noted "other treatment" options you should be aware that there are risks and benefits of such options and you may wish to discuss these with your primary medical physician.

 

The risks and dangers attendant to remaining untreated:

Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Symptoms may increase and over time this process may complicate treatment making it more difficult and less effective the longer it is postponed.

 

DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE.

 

NOTICE: You are required to sign and date these documents again once you are in our office for your visit.