Informed Consent Document

To the patient: Please read this entire document prior to signing it. It is important that you understand the information contained in this document. Please ask questions before you sign if there is anything that is unclear.

The nature of the chiropractic adjustment:

The primary treatment used in our office is spinal manipulative therapy. The doctor will use that procedure to treat you. The doctor may use their 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 may have experienced when you "crack" your knuckles. You may also feel a sense of movement.

Analysis/Examination/Treatment:

As part of the analysis, examination, and treatment, you are consenting to the following procedures: spinal manipulative therapy, range of motion testing, muscle strength testing, ultrasound/cold laser, palpation, orthopedic testing, posture analysis, hot/cold therapy, vital signs, basic neurological testing, electric muscle stimulation.

The material risks inherent in chiropractic adjustment:

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 the neck have been associated with injuries to the arteries in the neck leading to or contributing to soreness following the first few days of treatment. The doctor 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 responsibility to inform the doctor.

The probability of those risks occurring:

Fractures are rare occurrences and generally result from some underlying weakness of the bone, which the doctor will 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 medications, muscle relaxants, and pain killers, hospitalization, and/or surgery.
If you choose 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 risk 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. 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. PLEASE CHECK THE APPROPRIATE BLOCK AND SIGN BELOW.

HIPAA STATEMENT

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

In the course of your care as a patient at Stamford Family Wellness, we may use or disclose personal and health related information about you in the following way:

• Your personal health information, including your clinical records, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assessment, or treatment.
• Your health care records as well as your billing records may be disclosed to another party, such as an insurance carrier, an HMO, a PPO, or your employer, if they are or may be responsible for the payment of your services.
• Your name, address, phone number, and your health care records may be used to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information that may be of interest to you.

If you are not at home to receive an appointment reminder, a message may be left on your answering machine.  Further, you have the right to inspect or obtain a copy of the information we will use for these purposes.  You also have the right to refuse to provide authorization to contact you regarding these matters.  If you do not provide authorization, it will not affect the care provided to you or the reimbursement avenues associated with your care.

Under federal law, we are also permitted or required to use or disclose your health information without your consent or authorization in these following circumstances:

• If we are providing health care services to you based on the orders of another health care provider
• If we provide health care services to you in an emergency
• If we are required by law to provide care to you and we are unable to obtain your consent after attempting to do so
• If there are substantial barriers to communicating with you, but in our professional judgment we believe that you intend for us to provide care
• If we are ordered by the courts or another appropriate agency

Any use or disclosure of your protected health information, other than as outlined above, will only be made upon your written authorization.

We normally provide information about your health to you in person at the time you receive chiropractic care from us.  We may also mail information to you regarding your healthcare or about the status of your account.  If you would like to receive this information at an address other than your home, or if you would like the information in a different form, please advise us in writing as to your preferences.

You have the right to inspect and/or copy your health information for seven years from the date that the record was created, or as long as the information remains in our files.  In addition, you have the right to request an amendment to your health information.  Requests to inspect, copy, or amend your health related information should be provided to us in writing.

We are required by state and federal law to maintain the privacy of your patient file and the protected health information therein.  We are also required to provide you with this notice of our privacy practices with respect to your health information.

We are further required by law to abide by the terms of this notice while it is in effect.  We reserve the right to alter or amend the terms of this privacy notice.  If changes are made to our privacy notice, we will notify you in writing as soon as possible following the changes.  Any change in our privacy notice will apply for all of your health information in our files.

Information that we use or disclose based on the privacy notice may be subject to re-disclosure by the person to whom we provide the information and may no longer be protected by the federal privacy rules.

If you have a complaint regarding our privacy notice, our privacy practices, or any aspect of our privacy activities, you should direct your complaint to Dr. Damian Ortelli immediately.

If you would like further information about our privacy practices, please contact Dr. Damian Ortelli.

This notice is effective as of April 1, 2003.  This notice, and any alterations or amendments made hereto, will expire seven years after the date upon which the record was created. 

Assigned Benefits Form

I request that payment of authorized benefits be made to Stamford Family Wellness, for any services rendered. I authorize that payment for services rendered be sent directly to Stamford Family Wellness at the above listed address.

I authorize any holder of medical information about me to be released if needed to determine these benefits for related services.

I understand that I am financially responsible to Stamford Family Wellness if services recommended are not covered under my health plan, if my eligibility is not confirmed prior to treatment, if charges for services exceed my plan's maximum benefits, or if my employment or insurance status has been altered.

Cancellation Policy

We value all of our patients' time. In order to maximize our efficiency, we are instituting a new cancellation policy. Effective Marc 1, 2014:

Our cancellation fee is $25.

We ask that you please give us 24 hours notice of cancelling or changing your appointment time.

If you are unable to give us 24 hours notice but cancel or change your appointment more than 30 minutes prior to your scheduled time, we will waive the fee if you schedule a make-up appointment within the next week during the same phone call. Every effort should be made to keep you on your recommended care plan. For example, if you are scheduled to come in for 3 visits per week and can not make the 3rd appointment up during that week, you would then come in for four visits the following week to make up that appointment.

If you notify us less than 30 minutes before (or any time after) your scheduled appointment time, you will be charged the $25 fee.

If you do fail to notify us of a cancellation (no call/no show), three times in a one month period, you will be placed in "walk in only" status. This means that you may come in at any time for an appointment, but we will be unable to schedule appointments ahead of time for you.

We certainly understand that sometimes special circumstances arise. If you believe that your cancellation qualifies as a special circumstance, please bring it to Dr. Ortelli's attention.