309 W 12th St
Precision Chiropractic & Wellness
Informed Consent for Treatment
I hereby request and consent the performance of chiropractic procedures, various forms of physio-therapy, physical examination, x-ray studies, and/or any clinical services that are deemed necessary in my case to be administered by the doctor and/or any support staff employed or contracted by this office or clinic. I understand that,as with any health care procedure, complications due to chiropractic treatment have been labeled as "rare' and include, but are not limited to, muscle spasms, aggravating and/or temporary increase in symptoms, fracture, disc injury, stroke, dislocations, and sprains.
I understand that chiropractic adjustments and supportive treatment is designed to reduce and/or correct subluxations, allowing the body to return to improved health. It can also be used to alleviate other symptoms through a conservative approach with hopes to avoid more invasive procedures. I further understand that, as with all health care treatments, results are not guaranteed, and there is no promise to cure. I hereby acknowledged that if I do not keep appointments as recommended to me by my treating doctor, he/she has the right to terminate responsibility for my care and relinquish any disability granted me within a reasonable period of time. I further understand that there are other treatment options available for my condition and that I have the right to a second opinion should I have concerns as to the nature of my symptoms and or treatment options. If during the course of my care, my insurance company requires me to take an examination from any other doctor, I will notify this facility/physician immediately. I understand that failure to do so may jeopardize my case.
I have read the above consent, and I have had an opportunity to ask questions regarding its content. By signing below, I agreed to the above-named procedures and intend this consent to cover my entire course of treatment for my present condition and for any future condition(s) for which I seek treatment with this office
Health Insurance Portability and Accountability Act (HIPAA) Consent Form
Release of Information: Your protected health information (PHI) will be used by this office and/or disclosed to others for the purpose of treatment, obtaining payment, or supporting the day-to-day health care operations of this office. You should review the Notice of Privacy Practices for a more complete description of how your PHI may be used or disclosed. It describes your rights as they concern the limited use of health information, including your demographic information, collected from you and created or received by this office. You may review The Notice prior to signing this consent. You may request a copy of The Notice at the front desk. This office receives the right to modify the Privacy Practices outlined in The Notice
Requesting a Restriction on the Use or Disclosure of Your Information: You may request a restriction on the use or disclosure of your PHI. It is the policy of this office that it will continue to provide treatment for a patient who restricts consent to the use and disclosure of his or her PHI for the purposes of treatment, payment, or health care operations. Use or disclosure of protected information in violation of an agreed upon restriction will be a violation of the federal privacy standards.
Revocation of Consent: You may revoke the consent to the use or disclosure of your PHI. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected.
By signing, I acknowledged that I have reviewed the above information, and I authorized this office to release information concerning my condition and treatment to my insurance company, attorney, insurance adjuster and/or other health care providers deemed necessary for treatment purposes, concerning my claim or benefits, and payment of services rendered to me as well as coordinating treatment. I do understand that if I choose to refuse release of this information, that my PHI will be used within the office for purposes of my cares, to those individuals designated by the doctor.
Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to to arbitration as provided by state and federal law, and not by a lawsuit or sort to court process except as state and federal law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.
Article 2: All Claims Must be Arbitrated: It is also understood that any dispute that does not relate to medical malpractice, including disputes as to whether or not a dispute is subject to arbitration, will also be determined by submission to binding arbitration. It is the intention of the parties that this agreement bind all parties as to all claims, including claims arising out of relating to treatment or services provided by the health care provider including any heirs or past or past, present or future spouse(s) of the patient in relation to all claims, including loss of consortium. This agreement is intended to bind the patient and the health care provider and/or other licensed health care providers or preceptorship interns who now or in the future treat the patient while employed by, working or associated with or serving as a back-up for the health care provider, including those working at the health care provider's clinic or office or any other clinic or office whether signatories to this form or not. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the health care provider, and/or the health care provider's associates, association, corporation, partnership, employees, agents and estate, must be arbitrated including, without limitation, claims for loss of of consortium, wrongful death, emotional distress, injunctive relief, or punitive damages.
Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days thereafter. The neutral arbitrator shall then be the sole arbitrator and shall decide the arbitration. Each party to the arbitration shall pay such party's pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including couple fees, witness fees, or other expenses incurred by a party for such party's own benefit.
Either party shall have the absolute right to bifurcate the issues of liability and damage upon written request to the neutral arbitrator. The parties consent to the intervention and joinder in this arbitration of any person or entity that would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration.
The parties agree that provisions of the state and federal law, where applicable establishing the right to introduce evidence of any amount payable as a benefit to the patient to the maximum extend permitted by the law, limiting the right to recover non-economic losses, and the right to have a judgement for future damages conformed to periodic payments, shall apply to disputes within this Arbitration Agreement. The parties further agree that the Commercial Arbitration Rules of the American Arbitration Association shall govern any arbitration conducted to this Arbitration Agreement.
Article 4: General Provision: A:; claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding, a claim shall be waived and forever barred if (1) on the date of notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable legal statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence.
Article 5: Revocation: This agreement may be revoked by written notice delivered to the health care provider within 30 days of signature and if not revoked will govern all professional services by the patient and all other disputes between the parties.
Article 6: Retroactive Effect: IF patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment)/ Effective as the date of first professional services.
If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. My signature below, I acknowledgethat I have received a copy.
NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT
ELECTRONIC COMMUNICATIONS CONSENT FORMText Messaging / Emails Consent Form
Precision Chiropractic and Wellness can now communicate with patients using simple message service (SMS) text messages and emails. These can be received with an appropriate device (i.e. smart phone or tablet) and can include appointment reminders and general information.These services may also extend to sending other health information out to you in the future.
I understand that these messages are transmitted over public networks to a personal device and, as such, are not secure. I consent to the practice contacting me by text/email for the purposes of health information, appointment reminders, and other materials.
I also agree to advise the practice if my mobile number or email address changes to keep my records up to date.
The practice will not transmit any information that would enable an individual patient to be identified without prior consent.
The practice does not share mobile phone contact details or email addresses with any external organization(s).
Welcome to the office! Please take the time to review the following office guidelines and policies so that we may better help serve you. This information outlines our terms for providing service and will help clarify any questions you may have.
Preparation GuidelinesPrior to your initial visit, you will need to obtain all necessary paperwork. We ask that you read and complete this paperwork at home (in non-urgent cases) to give you time to think through your answers and to make the most out of your time in our office. You will receive all necessary documents from our office before your appointment. If you do not have access to a computer, please let the office know and we will provide you with a copy in the office.
If applicable, please bring copies of your latest laboratory and imaging (x-ray, MRI, CT) reports on the day of your initial exam. Please make copies for yourself beforehand, as the copies we receive will become part of your record in our office. If your doctor requires an "Authorization to Release Medical Records" form. Please contact our office, and we will provide one for you. Often your laboratory and imaging results can be faxed to you.
10:00 am-6:00 pm