Thank your for choosing Sports and Family Chiropractic. We know that in today’s competitive market place, patients have many choices when seeking care. We appreciate your choosing our office and know you made the best choice. Our continued reputation as one of the top chiropractic offices rests with each and every customer. Sports and Family Chiropractic stands behind our quality service and want to let you know we are here if you need us. Should you, a family member or friend, have need for care, please do not hesitate to have them contact us. Thanks, again.
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HEALTH CARE AUTHORIZATION: The patient identified above authorizes SFC (Sports & Family Chiropractic) to use and or disclose protected health information in accordance with the following Specific Authorizations: Patient Demographics: I give permission to SFC to use my address, phone number and clinical records to contact me with birthday cards, holiday related cards, and newsletters and information about treatment alternatives or other health related information. We do not share this information with others. Open Room Adjustments: I give SFC 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 doctor at any time in private; the doctor will provide a room for these conversations. Patient Health Information: By signing this form you are giving SFC permission to use and disclose your protected health information in accordance with the directives listed above (patient testimonials). Expiration: The Authorization shall renew on the following date: January 1, of each year, unless a written notice of cancellation is given. Right To Revoke Authorization: You have the right to revoke this AUTHORIZATION, in writing, at any time. However, your written request to revoke this AUTHORIZATION is not effective to the extent that we have provided services or taken action in reliance on your authorization. How to Revoke Authorization: You may revoke this authorization by mailing or hand delivering a written notice to the Privacy Official of SFC. The written notice must contain the following information: Your name, Social Security number and date of birth; A clear statement of your intent to revoke this authorization; The date of your request; and your signature. The revocation is not effective until the Privacy Official receives it. Use/Disclosure of Patient Health Information: This authorization is requested by SFC for its own use/disclosure of PHI. (Minimum necessary standards apply.) You have the right to refuse to sign this authorization. If you refuse to sign this authorization, SFC will not refuse to provide treatment. You Have The Right To Inspect Or Copy The PHI To Be Used/Disclosed. *A copy of the signed authorization will be provided to you upon request. Financial Policy: Welcome. Sports & Family Chiropractic are committed to your care being successful. Payment of your service is considered an integral part of your health benefits. To ensure the best results and uninterrupted care we appreciate your cooperation with the following: Scheduled Appointments you will be served in the order of your reserved time. When you are in the adjustment room, lie face down, rest and take a few moments to breathe. Releasing some of the stress and strain on your muscles and mental attitude is very helpful before your Chiropractic adjustment. Changes to an appointment should be made 24 hours in advance to avoid a $28 service fee, including Massage Appointments. Cancellations can be left on our answering machine. Reschedules should be done directly with the front desk. If you need to change the time of your appointment and the same day is not possible, be sure to make up your appointment within the week. Expect to pay your portion at the time service is rendered to avoid processing fees of $5 per day. An immediate change in your financial arrangement with this office may occur due to changes you make in your treatment plan. When you pay by check, if your check is dishonored or returned for any reason, a processing fee of $25 will be assessed. The use of a check for payment is your acknowledgment and acceptance of this policy and its terms. $8 late fees per bill, per month is assessed to accounts 30 days past due. Accounts are delinquent at 45 days. Accounts will be forwarded to our collections department at 60 days and subject to any and all collection-processing fees. Insurance Policies are not a guarantee or authorization of payment. They are solely contracts between the subscriber and the insurance company. Ultimate financial responsibility lies with you, the patient. Carefully review your "Explanation of Benefits" when received in the mail. Call your insurance carrier directly to resolve any discrepancies on your claims, to avoid out of pocket expenses. Accepting assignment and/or liens is done so under a pre-qualified understanding between the patient, this office and the third party payor(s). Establishing an honest ethical working relationship allows this office to continue accepting liens and assisting patients in their goals for better health. Any and all changes of the original partys agreement, independent of this offices knowledge or consideration, immediately disqualifies the terms of that agreement and demands immediate payment on the outstanding balance. Financial arrangements are valid under your present condition. They are subject to renewal by the start of each New Year. Should changes arise in your medical or financial situation that would affect your current financial agreement, you must notify this office prior to your care. Should you discontinue care or be released from further service, at this office, all outstanding balances are due upon notification. Terms of Acceptance: Chiropractic has only one goal. To eliminate a major interference to the expression of the bodys innate wisdom. Our only method is specific adjusting to correct vertebral subluxations. Adjustment: an adjustment is the specific application of force to facilitate the body’s correction of vertebral subluxation. Health: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity. Our Happy “Healthy” Hour is a complimentary service mandatory for all Wellness Patients. We offer 1) The Secrets of Optimum Health, 2) The 5 Factors of Health, and 3) Peak Performance. Each hour details how the body functions, things you can do in your daily activities for long-term results and how Chiropractic works. We suggest bringing a partner and/or loved one(s) who may benefit from this information on daily health. Progress Evaluations and Updates: During your course of care, progress exams are done to measure your progress. Vertebral Subluxation: A misalignment of one or more of the 24 vertebrae in the spine causing interference of nerve function and transmission of mental impulses, resulting in a lessening of the bodys innate ability to express it’s maximum health potential. We are here for your health needs. Please speak directly with Dr. Wright, should any upsetting matter occur. Your comments and participation guide us to the best possible care and service we can provide you. We do not offer to diagnose or treat any disease or condition other than vertebral subluxation, and neuromusculoskeletal, (nerve, muscles, and bone). However, if during the course of a chiropractic spinal examination, we encounter non-chiropractic or unusual findings, we will advise you and or refer you to a specialist as needed. I have read and fully understand the above.
* Please read and agree to the terms
Today's Date: 21 Oct 2018