Health Care Authorization Form

Energetic Spine Chiropractic. 1271 S Broad St. Wallingford, CT 06492 (203) 626-9252

Health Care Authorization form

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 Energetic Spine Chiropractic, we may use or disclose personal and health related information about you in the following ways:

·  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, to provide information about alternatives to your present care, or to 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 for this office to contact you regarding these matters. If you so not provide us with this 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 requited to use or disclose your health information without your consent or authorization in the 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 an in 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 or your protected health information, other than as described in the examples outlined above, will only be made upon your written authorization.

Energetic Spine Chiropractic. 1271 S Broad St. Wallingford, CT 06492 (203) 626-9252

This Notice of Privacy Practices also describes my rights and duties of the Chiropractor with respect to protected health information. I hereby give Energetic Spine Chiropractic to use and/or disclose Protected Health Information in accordance with the following:

·  I give permission to Energetic Spine Chiropractic to use my address, phone number and clinical records to contact me with appointment reminders, missed appointment notification, birthday cards, holiday related cards, newsletters, information about treatment alternatives or other health related information.

·  If Energetic Spine Chiropractic contacts me by phone, I give permission to leave a phone message on my answering machine or voice mail.

·  I give Energetic Spine Chiropractic to use my first name on a welcome board, referral board, and birthday board.

·  I give permission to Energetic Spine Chiropractic to use any photograph on their patient picture bulletin board and other marketing materials such as their brochure, website, and ads in print media.

·  I give permission to Energetic Spine Chiropractic to use any testimonial written by me for marketing purposes such as sharing with other patients or potential patients, in their brochure, on their website or in ads in print media.

·  I give Energetic Spine Chiropractic permission to treat me in an open room where other patients are also being treated. I am aware that other persons in the office may overhear some of my protected health information during the course of care. Should I need to speak with the doctor at any time in private, the doctor will provide a room for these conversations.

·  By signing this form you are giving Energetic Spine Chiropractic permission to use and disclose your protected health information in accordance with the directives listed above.

Office Policy Regarding Insurance Assignment

We will gladly accept assignment of your insurance benefits, once your exact coverage is verified. We will file your claim forms and assist you in any way that we can.

We offer this courtesy with these understandings:

·  Your contract is between you and your insurance company; you are responsible for any amount not covered or paid by your insurance (deductibles, copayments, denials, etc).

·  All payments /charges are subject to correction, based on insurance company’s “Usual, Reasonable, and Customary” Fee Schedule. Any corrections will be made after we receive the first insurance check.

·  Our office does not guarantee that your insurance will pay. We will make every attempt, at the beginning of your care, to verify your policy and what it covers. However, if for some reason your insurance claim is denied, you are responsible for the full amount of your bill.

·  Your insurance should pay within 30 days. If your insurance has not paid within 60 days, you must pay the balance due and be reimbursed by your insurance company when and if it pays.

Energetic Spine Chiropractic. 1271 S Broad St. Wallingford, CT 06492 (203) 626-9252

·  Our office will not enter into a dispute with your insurance company over your claim. This is your responsibility and obligation.

RIGHT TO REVOKE AUTHORIZATION:

If there is one or more of the bullets above you do not give authorization for, please state it/them here ______.

You have the right to revoke this authorization, in writing, at any time. However, your written request to revoke this authorization is no effective to the extent that we have provided services or taken action in reliance with your authorization.

You may revoke this authorization by mailing or hand delivering a written notice to the privacy official of Energetic Spine Chiropractic. The written notice must contain the following information:

Your name, SS#, and DOB;

A clear statement of your intent to revoke this authorization;

The date of your request; and

Your signature/

The revocation is not effective until it is received by the privacy official.

This authorization is requested by Energetic Spine Chiropractic for its own use/disclosure of PHI.

(Minimum necessary standards apply).

I have the right to refuse to sign this authorization. If I refuse to sign this authorization, Energetic Spine Chiropractic will not refuse to provide treatment however, it will not be possible for Energetic Spine Chiropractic to file third party billing on my behalf and I will be responsible for 1) payment in full at time of services are provided to me 2) scheduling my own appointments since Energetic Spine Chiropractic will be unable to contact me 3) all contact with Energetic Spine Chiropractic regarding my care. Additionally, any collection activity as permitted by law is not waived by refusal to sign the authorization

I have the right to inspect or copy, within boundaries, the protected health information to be used/disclosed. A reasonable fee for copying will apply. A copy of the signed authorization will be provided to me.

HEALTHCARE AUTHORIZATION

I have read and understand this Healthcare authorization form. My signature below represents agreement with these practices.

Patient’s Name (please print):______

DOB:______

Patient Signature:______

Today’s Date:______

Name of Personal Representative (if someone is designated to act on your behalf/or for a minor)

Parent or Personal Representative name (please print):______

Signature:______Relationship:______