Balanced Health
HIPAA Compliant
Consent for Purposes of Treatment, Payment & Healthcare Operations (3/03)
In this document, “I” and “my” refer to the patient, and “Chiropractor” refers to Balanced Health Chiropractic Center of West Michigan P.L.C.
I consent to the use or disclosure of my protected health information by Chiropractor for the purpose of analyzing, diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of Chiropractor. I understand that analysis, diagnosis or treatment of me by Chiropractor may be conditioned upon my consent as evidenced by my signature below.
I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment or healthcare operations of the practice. Chiropractor is not required to agree to the restrictions that I may request. However, if Chiropractor agrees to a restriction that I request, the restriction is binding on Chiropractor.
I have the right to revoke this consent, in writing, at any time, except to the extent that Chiropractor has taken action in reliance on this Consent.
My "protected health information" means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.
I have been provided with a copy of the Notice of Privacy Practices of Chiropractor and understand that I have a right to read the Notice prior to signing this document. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Chiropractor. The Notice of Privacy Practices for Chiropractor is also posted in the waiting room at 300 S. State St., Suite 4, Zeeland. This Notice of Privacy Practices also describes my rights and duties of the Chiropractor with respect to my protected health information.
Chiropractor reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office of Chiropractor and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.
Signature of Patient or Personal Representative Printed Name of Patient
Date of Signing Description of Personal Representative’s Authority
On the line above, list the names of anyone with whom we can discuss your care/billing.
ATTENTION MEDICARE PATIENTS: Medicare and its supplements do not cover exams or x-rays. Therefore the costs of these services are your responsibility.
One Time Authorization Agreement
I, ______Medicare Number______request that payment of authorized Medicare benefits be made either to me or on my behalf to Dr.______for any services furnished to me by that physician. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services (formerly known as the Health Care Financing Administration) and its agents any information needed to determine these benefits or the benefits payable for related services.
______
Beneficiary Signature Date
Balanced Health
Financial Policy and Agreement
The purpose of this agreement is to clarify the financial aspects of your care. Our goal is to devote our efforts to helping you get well and reaching your personal health goals.
SERVICES - The following are all services we provide a long with all our fees:
Consultation Free Initial Exam (history, physical, posture analysis) $40
Office Visit (No adjustment) $40 X-rays (per film) $35
Adjustment of 1 – 2 regions $40 Muscle Scan $20
Adjustment of 3 – 4 regions $40 Progressive Exam (Re-exam) $40
INSURANCE - If Balanced Health has verified that your insurance will cover chiropractic care received from this office, your claims will be filed. However, it is very rare that insurance companies will cover all chiropractic costs and the charges that are not paid by your insurance are your responsibility.
If you choose to file your own claims we will provide you with the necessary information for reimbursement from your health or auto insurance. We will not become legally involved in disputes involving deductibles, co-payments, covered charges, secondary insurance, “usual and customary” charges, etc., except to supply factual information.
FORMS OF PAYMENT - All services rendered are the ultimate responsibility of the person receiving care or their responsible guardian. Prepay options, which include up to 20% savings, and flexible payment options are available upon request. If your insurance does not cover care provided from Balanced Health Chiropractic Center of West Michigan, P.L.C. all charges incurred are the patient’s responsibility to pay at the time care is given. You may choose to pay by check, credit card, or cash.
RIGHT TO CARE - We believe that each person who is committed to pursuing improved health has the right to receive NUCCA chiropractic care. That being the case, we have never denied anyone NUCCA care because of the inability to pay. If special arrangements are necessary, please discuss your concerns with the doctor.
BILLING AND OUTSTANDING BALANCES - In the rare event of an outstanding balance, statements are sent at the beginning of the month. Balances are considered past due if not paid by the 15th or when special arrangements are not met. Our hope is to remedy outstanding balances without the use of a collection agency and expect communication from you if your ability to uphold an established financial agreement has changed. Returned checks are subject to a $30 fee.
If my account is delinquent, I agree to pay all expenses incurred by this office to collect the account. This includes, but is not limited to, items such as collection agency fees (additional 33%), court costs, and attorney fees.
MISSED APPOINTMENT POLICY - In the rare event that you cannot make it to your regularly scheduled appointment we require a call 24 hours in advance of the appointment. Missed appointments will be charged a $45 fee.
QUESTIONS - Please ask questions about this agreement or if your ability to comply with its provisions change. Please ask if you would like to receive a copy of this agreement.
SIGNATURE - I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered to me will be immediately due and payable.
Patient/Responsible Party Signature Date