CHILD HISTORY FORM

Please complete this detailed history form. Should you require any assistance, please let us know as we will be happy to assist.

History of Birth

Growth and Development

The following information is very important because many of the problems that chiropractors work with are caused by stressors.

Chemical Stressors

Psychological Stressors

Traumatic Stressors 

I hereby authorize and consent to the chiropractic evaluation and care of my child.

INFORMED CONSENT

We encourage and support a shared decision-making process, between us, regarding your health needs. As part of that process, you have a right to be informed about the condition of your health and the recommended care and treatment to be provided to you so that you can make the decision whether or not to undergo such care with full knowledge of the known risks. This information is intended to make you better informed in order that you can knowledgeably give or withhold your consent.

Chiropractic is based on the science which concerns itself with the relationship between structures (primarily the spine) and function (primarily of the nervous system) and how this relationship can affect the restoration and preservation of health.

Adjustments are made by chiropractors in order to correct or reduce spinal and extremity joint subluxations. A vertebral subluxation is a disturbance to the nervous system and is a condition where one or more vertebra in the spine is misaligned and or does not move properly causing interference and or irritation to the nervous system. The primary goal in chiropractic care is the removal and or reduction of nerve interference caused by vertebral subluxation.

A chiropractic examination will be performed which may include spinal and physical examination, orthopedic and neurological testing, palpitation, specialized instrumentation, radiological examination (x-rays), and laboratory testing.

The chiropractic adjustment is the application of a precise movement and or force into the spine in order to reduce or correct vertebral subluxation(s). There are several different methods or techniques by which the chiropractic adjustment is delivered but are typically delivered by hand. Some may require the use of an instrument or other specialized equipment. In addition, physiotherapy or rehabilitative procedures may be included in the management protocol. Among other things, chiropractic care may reduce pain, increase mobility and improve quality of life.

In addition to the benefits of chiropractic care and treatment, one should also be aware of the existence of some risks and limitations of this care. The risks are seldom high enough to contraindicate care and all health care procedures have some risk associated with them.

Risks associated with some chiropractic treatments may include soreness, musculoskeletal sprain strain, and fracture. Risks associated with physiotherapy may include the preceding as well as allergic reaction and muscle and or joint pain. In addition, there are reported cases of stroke associated with visits to medical doctors and chiropractic treatment and the occurrence of stroke; rather, recent studies indicate that patients may be consulting medical doctors and chiropractors when they are in the early stages of a stroke. In essence, there is a stroke already in process. However, you are being informed of this reported association, because a stroke may cause serious neurological impairment.

I have been informed of the nature and purpose of chiropractic care, the possible consequences of care, and the risk of care, including the risk that the care may not accomplish the desired objective. Reasonable alternative treatments have been explained, including the risks, consequences, and probable effectiveness of each. I have been advised of the possible consequences if no care is received. I acknowledge that no guarantees have been made to me concerning the results of the care and treatment.

I HAVE READ THE ABOVE PARAGRAPH. I UNDERSTAND THE INFORMATION PROVIDED. ALL QUESTIONS I HAVE ABOUT THIS INFORMATION HAVE BEEN ANSWERED TO MY SATISFACTION. HAVING THIS KNOWLEDGE, I KNOWINGLY AUTHORIZE SOURCE FAMILY CHIROPRACTIC TO PROCEED WITH CHIROPRACTIC CARE AND TREATMENT.

INSURANCE AND FINANCIAL POLICY

The purpose of this is to let you know how our office works in the handling of your insurance claims. We do this to eliminate any questions or misunderstandings that could arise and later affect your ability to use your policies as they were intended.

Insurance:

Source Family Chiropractic, Inc. will verify your insurance as a service to you. Because we are an out-of-network provider in all insurance plans, any submitting of insurance claims will be done by the patient after receiving a statement of services received and paid. Because we itemize every procedure rather than just describe what is being done as an "office visit", the charges per visit can vary from $40 to $150 per visit (excluding the initial visit) with all discounts disclosed in the statement. These charges depend on the individual needs of each patient. We know that there are a lot of changes that will not be paid for various reasons and we expect to receive denials on some claims because it is the nature of the insurance industry. Most insurance companies decide for you what is medically necessary, regardless of or recommendations or your health desires. However, we will bill for all services rendered in order to adequately and honestly communicate with your insurance.

If our office does not hear from your insurance company within 30 days, we will request your help in contacting your insurance company to resolve the payment delay. It is your responsibility to make sure that copies of any and all correspondences from your carrier be given to us. An insurance plan is a contract between you and your insurance company. We must hold you responsible for any balance due.

Payment of Services:

I understand I am financially responsible for all charges and fees related to the services rendered to me by Source Family Chiropractic, Inc. I further understand that the payment in full is expected upon receipt of the first statement which may include deductibles and any services not covered by insurance.

Assignment of Benefits:

I hereby authorize payment directly to the center by my insurance company(s). In the event an overpayment is made from more than one insurance company, I understand the overpayment will be sent to the appropriate payer. If my insurance company sends the payment directly to me instead of mailing it to the office, I will bring the payment to you, to save me from being billed later.

Authorization for Release of Information:

I authorize Source Family Chiropractic, Inc. to disclose all or any parts of the patient's chiropractic record to listed insurance companies, government agencies, the patient's employer, or other payment sources. I also understand that I may revoke this authorization by providing written notice to this practice.

Notice of Privacy Practices:

I hereby acknowledge that I have received a copy of the center's Notice of Privacy Practice.

Should any questions arise regarding the financial policies of this office, please notify us on your next visit. We are here to serve you.

We are committed to providing you with the best chiropractic care possible in a caring environment and have established our financial policies to achieve that goal. You will be expected to pay for your chiropractic care at the time of service is rendered unless other arrangements are made in advance. Our office has payment plans available that are designed to be the most cost-effective way to keep you and your family as healthy as possible. Details of these plans will be discussed with you during your second visit.

As a new member of our practice, you have two different options to choose from:

Patient Self Pay:

The patient pays for care using a payment method that best suits their needs (eg. Cash, Check, Credit, including Visa, Master Card, Discover, American Express). Fee Discounts may be available for certain payment options or packages.

Out of Network Health Insurance:

As a courtesy to you, if you have insurance that covers out-of-network chiropractic, we will provide the paperwork for you to submit to your insurance carrier. Please remember that your insurance coverage is a contract between you and your insurance company. Depending on your specific coverage, you may be asked to pay either your deductible and/or maximum out of pocket before any coverage begins. These details will be discussed with you on your second visit once your insurance has been verified. (You will be considered a non-insurance patient until your insurance is verified).

I have read and understand the Insurance and Financial Policy for Source Family Chiropractic, Inc. and realize that any combination of these fees may be charged when such services and rendered to me and/or my family members. I agree that my account with Source Family Chiropractic, Inc. is my responsibility and I agree to satisfy any balance that has gone unpaid over 60 days. If I default on my account, I agree to pay all costs of collection, including collection agency fees and/or reasonable attorney's fees. Furthermore, I understand that these procedures and fees and subject to change without prior notice.

HEALTH CARE AUTHORIZATION FORM

I have been provided with a copy of the Notice of Privacy Practices for Protected Health Information. The Notice of Privacy Practices describes the types of uses and disclosures of my Protected Health Information (PHI) that will occur in my treatment, payment of my bills, or in the performance of health care operations of this chiropractic office. A copy of our notice is attached, and we encourage you to read it and request your own copy if you would like one.

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

SPECIFIC AUTHORIZATIONS:

•I give permission to Source Family Chiropractic to use my address, phone number, and clinical records to contact me with appointment reminders, missed appointment notifications, birthday cards, holiday-related cards, newsletters, information about treatment alternatives, or other health-related information.

•If Source Family Chiropractic contacts me by phone, I give them permission to leave a phone message on my answering machine or voice mail.

•I give permission to Source Family Chiropractic to use my name on a welcome board, referral board, and birthday board.

•I give permission to Source Family Chiropractic to use my 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 Source Family 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 Source Family 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 a doctor at any time in private, the doctor will provide a room for these conversations.

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

The use of this format is intended to make your experience with our office more efficient and productive as well as to enhance your access to quality health care and health information. This authorization will remain in effect for the duration of my care at Source Family Chiropractic plus 7 years or until revoked by me.

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.

You may revoke this AUTHORIZATION by mailing or hand-delivering a written notice to the Privacy Official of Source Family Chiropractic. 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 it is received by the Privacy Official.

This AUTHORIZATION is requested by Source Family 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, Source Family Chiropractic will not refuse to provide treatment however, it will not be possible for Source Family Chiropractic to file third-party billing on my behalf and I will be responsible for 1)payment in full at the time services are provided to me 2) scheduling my own appointments since Source Family Chiropractic will be unable to contact me 3) all contact with Source Family 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.