Please fill out your Health Record as completely and accurately as possible. If you have any questions, please don't hesitate to ask one of our qualified Chiropractic Assistants.
It is our pleasure to be of service to you. Our commitment to you is to promote the highest quality of health and well-being through natural Chiropractic care.
Confidential Patient Information
Employer Information
Reason For This Visit
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EXPERIENCE WITH CHIROPRACTIC
GOALS FOR MY CARE
People see Chiropractors for a variety of reasons. Some go for relief of pain, some to correct the cause of their pain, and others for correction of whatever is malfunctioning in their bodies. Your Doctor will weigh your needs and desires when recommending your treatment program.
Please check the type of care desired so that we may be guided by your wishes whenever possible.
HEALTH CONDITIONS
Please check each of the diseases or conditions that you have had now or in the past. While they may seem unrelated to the purpose of the appointment, they can affect the overall diagnosis, care plan and the possibility of being accepted for care.
HEALTH HABITS
FOR WOMEN ONLY:
EMERGENCY CONTACT
HIPAA - PATIENT PRIVACY
THIS NOTICE DESCRIBES HOW CHIROPRACTIC AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
In the course of your care as a patient at Frain Family Chiropractic we may use or disclose personal and health related information about you in the following ways;
1. Your protected health information, including your clinical records, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assessment or treatment.
2. Your health care records as well as your billing records may be disclosed to another party, such as an insurance carrier, agent, adjuster, HMO, PPO, or your employer, if they maybe responsible for the payment of services provided to you.
3. Your name, address, phone number, and your health care records may be used by our office only to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information.
You have a right to request restrictions on our use of your protected health information for treatment, payment and operations purposes. Such requests are not automatic and require the notice to this office.
Your name, address, telephone number, e-mail address and health records may be used to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information that maybe of interest to you. If you are not home to receive an appointment reminder or other related information, a message may be left on your answering machine or with a person in your household.
You have a right to confidential communications and to request restrictions relative to such contacts. You also have the right to be contacted by alternative means or at alternative locations.
We are permitted and may be required to use or disclose your health information without your authorization in these following circumstances:
1. If we provide health care services to you in an emergency.
2. If we are required by law to provide care to you and we are unable obtain your consent after attempting to do so.
3. If there are substantial barriers to communicating with you, but in our professional judgment we believe that you intend for us to provide care.
4. If we are ordered by the courts or another appropriate agency.
You have the right to receive an accounting of any such disclosures made by this office. Any use or disclosure of your protected health information, other than as outlined above, will only be made upon your written authorization. If you provide an authorization for release of information you have the right to revoke that authorization at a later date. Information that we use or disclose based on this privacy notice may be subject to re-disclosure by the person to whom we provide the information and may no longer be protected by the federal privacy rules. We normally provide information about your health to you in person at the time you receive chiropractic care from us. We may also mail information to you regarding your health care or about the status of your account. If you would like to receive this information at an address other than your home or if you would like the information in a specific form please advise us in writing.
You have the right to inspect and/or copy your health information for as long as the information remains in our files. In addition you have the right to request an amendment to your health information.
Requests to inspect, copy or amend your health related information should be provided to us in writing. We are required by state and federal law to maintain the privacy of your patient file and the health protected health information therein.
We are also required to provide you with this notice of our privacy practices with respect to your health information.
We are further required by law to abide by the terms of this notice while it is in effect. We reserve the right to alter or amend the terms of this privacy notice. If changes are made to our privacy notice we will notify you in writing as soon as possible following the changes. Any change in our privacy notice will apply for all your health information in our files. If you have a complaint regarding our privacy notice, our privacy practices or any aspect of our privacy activities you should direct your complaint to: If you would like further information about our privacy policies and practices please contact: You also have the right to lodge a complaint with the Secretary of the Department of Health and Human Services. If you choose to lodge a complaint with this office or with the Secretary your care will continue and you will not be disadvantaged by this office or our staff in any manner whatsoever.
This notice is effective as of April 2023, and any alterations or amendments made hereto will expire seven years after the date upon which the record was created.
My signature acknowledges that I have received a copy of this notice.
FINANCIAL POLICIES
We are committed to providing you with the highest quality chiropractic care in a cost-effective manner. To help you understand your financial responsibility, please review our financial policy below. Please bring your insurance card with you to your appointment for verification of benefits. We will verify all benefits per your agreement with your carrier. After verification the Doctor will give his/her recommendations and an appropriate plan will be designed for each individual. Please let the front-desk know if you have been in some type of accident or have been injured on the job. This will enable us to give you any and all information necessary to serve you completely and accurately.
Payment Responsibility
All services rendered are the responsibility of the patient, regardless of insurance coverage.
Patients are financially responsible for any co-pays, deductibles, non-covered services, or balances not paid by insurance.
Payment is due at time services are rendered unless other financial arrangements are made.
Payment is due at the time products are ordered. This includes pillows, custom orthotics, supplements, therapy equipment, etc…
Insurance Billing
Your insurance policy is an agreement between you and your insurance provider and it is your responsibility to know and understand your coverage.
As a courtesy, we will bill your primary and secondary insurance providers on your behalf.
In order to do so, we require a current copy of your insurance card and valid ID on file.
Medicare Patients: Medicare does NOT cover x-rays, exams, therapies, products, or supplies. These charges are the patient’s responsibility.
You are responsible for:
Knowing your insurance benefits
Notifying us of any insurance changes
Understanding whether chiropractic care is covered
Note: Insurance coverage is not a guarantee of payment.
Payment Options
We accept the following forms of payment:
Cash
Credit/Debit Cards (Visa, Mastercard, etc.)
Health Savings Accounts (HSA) / Flexible Spending Accounts (FSA)
Payment Plans - Payment plans must be pre-approved and require a credit/debit card on file. No exceptions.
Payment is due at the time services are rendered, unless other arrangements have been made in advance.
Personal Injury/Auto Accidents
While we accept cases involving personal injury or motor vehicle accidents, you are ultimately responsible for payment of services not covered by third-party payers or if your case is denied or delayed.
Missed or Cancelled Appointments
We kindly ask for 24-hour notice for cancellations or reschedules.
A $25 fee may be charged for no-show appointments or same-day cancellations.
This fee is not billable to insurance.
Outstanding Balances
Statements will be sent monthly for any patient with a balance who is not on a payment plan.
Accounts over 60 days past due may be subject to collection action and associated fees.
If special financial circumstances arise, please speak to our front desk staff immediately to discuss payment arrangements.
Consent & Acknowledgement
By signing below, I acknowledge and agree that the information I have provided is accurate to the best of my knowledge. I acknowledge and agree to the terms of this financial policy. I understand that I am financially responsible for all charges incurred at Frain Family Chiropractic Wellness Center. I authorize the release of necessary health information for billing and insurance purposes.
I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.
