AUTHORIZATION FORM

Privacy Policies

Patients Name*

Date

Email*

Phone*

I have been given an opportunity to review Paragon Chiropractic & Wellness Center’s notice of privacy practices written in plain language. The notice provides the uses and disclosure of my protected health information that may be made by this practice, my rights, and the practice’s legal duties with respect to my information.

I understand that Paragon Chiropractic & Wellness Center reserves the right to change the terms of its Notice of Privacy Practices and to make changes regarding all protected health information, at or controlled by this practice. If changes to the Policy occur, Paragon Chiropractic & Wellness Center will provide me an opportunity to review the review Notice of Privacy Practices upon request

Signature

Relationship to patient if signed by representative of patient

Authorization to use or Disclose Protected Health Information

I authorize Paragon Chiropractic & Wellness Center to release all protected health information to:

Name

Relationship

I have read all disclosers about my rights to release health information under regulation in title 42 Code of Federal Regulations, Part 2, and information defined by MCLA 333.5131. I understand that my protected health information disclosed under this authorization may be subject to disclosure by the individual named above and its privacy will no longer be protected by law.

Signature of patient

Date

Financial Policies, Insurance Authorization, and Informed Consent for Treatment

Patient Name

Date of Birth

Thank you for choosing us as your health care provider. This document is a summary of our financial policies, an explanation of your responsibilities, and authorization to bill your insurance on your behalf for services rendered. You may be responsible for co-pays, deductibles, and services provided which may not be considered a benefit under your policy. Your insurance may deny claims for a variety of reasons

1. The services provided may not be a benefit of your insurance policy or may not be covered when provided by our office (such as Physiotherapy modalities, heat, massage, traction, exercise instruction, nutritional advice and or supplements.)

2. You may have exhausted the benefits of the services provided. Medical Necessity or Medically Necessary generally means a determination based upon criteria and guidelines developed by your insurance carrier in consideration of generally accepted standards and practices. Their services must meet all of the following criteria:

a. It is generally accepted as necessary and appropriate for the patient’s condition, given the symptoms, and is consistent with the diagnosis and;

b. It is essential or relevant to the evaluation or treatment of the injury, condition, or illness and is not mainly for the convenience of the member of the Physician and it is reasonably excepted to improve the patient’s condition or level of function or, in the case of diagnostic testing, the results are used in the diagnosis and /or management of the patient’s care.

Patients/Responsible Party Agreement (please place your initials next to each statement)

If my physician does not participate with my insurance company or my insurance company does not pay for the services provided, or I do not have Insurance coverage, I agree to be personally and fully responsible for all payments.

I accept responsibility for all co-pays and or deductibles and agree to pay at the time of services.

I understand that a statement will be sent to my home address unless a request was made otherwise.

I understand there is a $25 return check fee for any personal check that is returned.

I understand that there is a $30 no show fee for Massage visits that are canceled without a 24 hour notice.

I understand that statements are sent out on a monthly basis. If payment is not made within the due date of the statement we reserve the right to add a $10 late fee each month that it goes unpaid. If I am experiencing financial difficulty and cannot pay the balance in full, it is my responsibility to contact the office and arrange a payment plan.

I understand that should my account be sent to a collection agency that a 30% collection fee will be assessed. Additionally any court or attorney fees that are incurred by this office will also be my responsibility.

I understand that the physicians time and my care is valuable. If I must cancel an appointment, I will call the office and reschedule the appointment in a timely manner.

I have signed this form prior to any services rendered and understand that if I do not meet my financial obligations with Paragon Chiropractic & Wellness Center, this may adversely affect the patient/physician relationship and the physicians may withdraw as care providers.

INFORMED CONSENT FOR TREATMENT

Please read the following statements carefully. Your signature at the bottom of this form indicates agreement with each of the statements listed above and gives us permission to provide services as indicated below.

Signature of Responsible Party