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If the patient is a minor please provide guarantor (responsible party) information:
Insurance Information
Primary Insured Information
If patient is a minor
Consent to services and treatment of Self or a Minor: I authorize the licensed doctor and whomever he/she designates to perform diagnostics, and therapeutic procedures, and administer care as medically needed.
Imaging: I authorize medical imaging such as X-Ray/CT/MRI as medically needed.
Please write down the names of any person(s) that we are able to communicate with regarding general issues, non-medical in nature including anyone in the household or at work able to retrieve voice or text messages, retrieve mail, answer the phone on your behalf or schedule your appointments, etc.
Please write down the names of any person(s) authorized to you care or any medical records and imaging i.e. regarding specific and medical in nature including anyone in the household or at work able to retrieve voice or text messages, retrieve mail, answer the phone on your behalf or schedule your appointments, etc.
This authorization is irrevocable until request of change is submitted in writing to PRONEURO HEALTH.
Please read the agreement below AND initial ALL blanks:
Our fees are based on the area averages for the specific services rendered. The severity of your condition coupled with the time needed for you to reach your health goals determines the amount/types of service.
The information received at the “verification of benefits” is in NO WAY a guarantee of payment by your insurance carrier. They reserve the right to deny payment.
You have employed your insurance company to work for you. We will not become involved in any disputes between you and your insurance company. At all times you are financially responsible for all services.
All product purchases are paid in full, at the time of purchase.
ProNeuro Health reserves the right to modify the financial agreement, discontinue the accepting of insurance or the manner of collection of payment for services rendered without notice.
However: Patients who may change insurance carriers or who currently have out-of-network chiropractic benefits:
If your insurance changes or your primary insurance is for “OUT-OF-NETWORK CHIROPRACTIC'' care, we will submit your claims for services on your behalf to your insurance company.
Your claims are submitted to your insurance company as a courtesy and benefit to you. You are liable for ALL unpaid services/balances at the time of service. We do not reduce/write off remaining balances.
Patient Agreement: A MINIMUM fee of $25 - $50 will be charged and collected if proper notice is not given for a schedule change or cancellation. The fee is NOT billed to your insurance company, you are responsible for the payment. If you are running late for an appointment, please contact the office as soon as possible so that we can do our best to accommodate you.
If you arrive late for the appointment there is a possibility of a required reschedule to provide you and other patients with a complete and effective visit. These policies are in place to provide every patient with the very best care possible.
that has been (or is being) obtained pursuant to the Consent and Release. The Likeness may be copyrighted, used and/or published individually or in conjunction with other photography or video works, and in any medium.
The undersigned waives any right to inspect or approve the Released Party’s copyright, use or publication of the Likeness, or the printed matter that may be used from all claims for libel, slander, invasion of privacy, infringement of copyright or right of publicity, or any other claim related to Likeness (collectively, “Claims”).
This release includes without any limitation any Claims related to blurring, distortion, alteration, optical illusion, use in composite form, whether intentional or otherwise, or use of a fictitious name, that may occur or be produced in the processing or publication of the Likeness.
THE UNDERSIGNED WARRANTS THAT THE UNDERSIGNED HAS READ THIS CONSENT AND RELEASE PRIOR TO THE SIGNING OF THIS DOCUMENT, THAT THE UNDERSIGNED UNDERSTANDS IT, AND THAT THE UNDERSIGNED FREELY ENTERS INTO THIS CONSENT AND RELEASE.
Please read this carefully. It concerns your individual, private healthcare information and how this information may be used and disclosed by this office and how you can get access to this information. Please review it carefully.
1) We have a legal, ethical, and moral obligation to protect your confidentiality. Any information about you and/or your family will be strictly confidential by all employees. No discussions about you outside of the patient care framework will be allowed, and any conversation between staff members that pertains to delivering you quality care will be held in a confidential and professional manner.
2) In order to provide quality care to you, we will need to access your private health care information for the purposes of treatment, payment and operations (such as quality assurance). In using this information, we comply with all state and federal laws pertaining to your privacy rights, including the Privacy and Security protections provided by the Health Insurance Portability and Accountability Act (“HIPAA”)
3) Specifically, we will need to disclose your private information under the following circumstances:
Sharing information for purposes of treatment: We will share information with all members of your treatment team, both within this office and with other providers (personal and Institutional) in order to provide you with the quality care and education/wellness programs.
Sharing of information for the purposes of payment: We will share all necessary information with your insurer(s) payor(s), governmental entities (such as Medicare, Medicaid, etc.) and their representatives involved in the billing process (including, but not limited to representatives, data warehouses, billing companies, etc.
Sharing of information for purposes of operations: We will share all information necessary for ongoing operations of this office, including (but not limited to) credentialing processes, peer review, accreditation, and compliance with all federal and state laws.
4) Your consent for use and disclosure of information as described may be revoked in writing at any time. Please notify the office/Privacy Officer if you ever decide to revoke your consent.
5) Your specific authorization will be required for the release of any information not included above. Your authorization will need to be in writing, and it will be specific to the disclosure requested.
6) This office will not release any information other than those incidents described above unless disclosure is required by law, a court, a legal process, or government agencies.
7) You have the right to inspect and copy your protected information, amend your record. Have reasonable requests for confidential communications accommodated and may obtain an accounting of disclosures. All other rights afforded to you by state and federal law will be honored as they are created. This office will attempt to comply with any of your requests if feasible.
Please contact the Privacy Officer if you have any questions about your rights, or with any other privacy related questions you may have.
8) This office will continue to respect you and your family’s privacy and confidentiality. The Privacy Officer is available to discuss any questions or concerns you may have regarding the security and privacy of you and/or your family’s private health information:
• I have received a copy of the “Notice of Privacy Practices” which details my privacy.
• I consent and authorize ProNeuro Health to utilize my PHI (Private Health Information). For health/wellness and treatment purposes as well as for internal administrative purposes.
• I consent and authorize the releasing of my PHI from ProNeuro Health to another service organization in direct regard to my health/wellness and treatment being performed by ProNeuro Health.
• I consent and authorize ProNeuro Health to discuss, document, provide and/or request PHI to/from another organization for means of collection of payment or reimbursement.
• I consent and authorize ProNeuro Health to discuss, document, provide and/or request PHI from another organization for administrative purposes.
• I have the right to dent and/or limit the use of my PHI. Should my requests and or choices affect my care as deemed necessary by the doctor, I understand that I may be released as a patient of ProNeuro Health
Below is a list of conditions which may seem unrelated to the purpose of your appointment. However, these questions must be answered carefully as these problems can affect your overall course of care.
CHECK ANY OF THE FOLLOWING CONDITIONS YOU HAVE HAD IN THE LAST 6 MONTHS:
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