Existing Patient (Medicare)

Please fill out the information below to the best of your capability. The more details we have about you and your lifestyle, history, and surroundings, the better we can understand how to treat you. Get in touch with us at [email protected] with any questions, or call the office at (949) 359-8385.

We are looking forward to you experiencing the magic of being Well Connected!

Patient Information

Full Legal Name *

Date of Birth *

Gender

Male

Female

Marital Status *

Phone *

Email *

Address *

City *

State *

Postal code *

Emergency Contact Name and Phone Number *

Have you ever had Chiropractic Care before?

Whom may we thank for referring you to us?

Is this injury/illness related to an automobile accident?

Initial Problem Record

What is your main complaint or problem?

When did this begin?

How did this begin?

Complaint #2

Complaint #2 - When did this begin?

Complaint #2 - How did this begin?

List Doctors (name & phone number or email) consulted for condition(s):

What makes your problem better?

What makes your problem worse?

Has this happened before?

This problem bothers me:

Do you have any other related or unrelated complaints you would like to address?

Financial Agreement

Read carefully and choose the plan that best fits you.

Plan #1 – Cash, Check or Charge (Non-Insurance) - The new patient appointment is $395 (unless additional x-rays are needed @ $30 per view) and regular follow-up visits are $80 paid at the time of service. Care packages are available for additional savings and can only be used for regular follow up visits. If interested, please ask the staff for the care plan pricing.

Plan #2 – Insurance - Please be aware that we are an out-of-network provider, with the exception of TriWest and Multiplan. If you have insurance that covers out of network chiropractic care, we will bill your out-of-network chiropractic benefits directly if the deductible is $1500 or less. It is your responsibility to determine the out of network chiropractic benefits (we will provide a detailed form that gives all the information you need from your insurance company to determine if you have out-of-network coverage.) It is required that you fill out the document completely after you talk to your insurance company if you wish to go through insurance at Well Connected Chiropractic. It is vital to have this page completely filled out to ensure we have the most up to date and correct information regarding your insurance plan. Until we receive insurance payments for your dates of services, regular follow up visits will remain $80.

Plan #3 - Auto Injury/ Personal Injury - We will need your MedPay benefits/health insurance information and attorney’s name as well as their telephone number (if applicable). Even when working with an attorney on a lien, we may collect copays at each time of service. In the event the lien is voided or MedPay benefits are exhausted, you are responsible for the bill in its entirety immediately. If while under treatment you decide to retain an attorney and your MedPay benefits are distributed to your attorney, you will be responsible for payment in full immediately at time of service going forward and for any outstanding balance the attorney has collected from your MedPay benefits.

PAYMENT PLAN OF MY CHOOSING

Notices - Please read and initial next to each line

All new patients will receive a re-exam approximately 8 weeks from their initial visit to determine progress and the direction of further treatment. This exam is $100, and all other re-exams during further treatment will be subject to the exam fees.
Appointments that are not cancelled at least 24 hours prior (M-Th 9am-5pm) will be subject to a no show/late cancellation fee.
There will be a $250 no show fee for failure to show up to your new patient appointment. We require at least 48 hours for any scheduling changes.
There is a 4% credit card processing fee for all transactions made with a debit or credit card. If you wish to avoid this credit card processing fee, you can pay with cash, check or Zelle. In the event of a refund, the 4% credit card processing fee is non-refundable.
Office policy is for all patients to keep a credit/debit card on file regardless of payment method.
In the event your account is sent to collections, there will be a 40% increase in your balance to cover service fees for the collection agency.

No-Show Policy

We are so thankful for the amazing people we have the opportunity to serve. We are always investing in ways to make the experience for our patients as positive as possible. Not showing up to your scheduled appointment not only affects our efficient system, it also affects other patients seeking care at Well Connected. It is vital that all patients show up to their scheduled appointments on time. If you need to cancel or reschedule a chiropractic or massage appointment, please notify us at least 24 hours before your scheduled appointment. You can call or text the office at (949) 359-8385. If no one answers or you call after hours, please leave us a detailed voicemail or send a text message. Doing so will count as sufficient notice if done at least 24 hours before your scheduled appointment. Any cancellations made after the end of the business day preceding your next appointment will be subject to a late cancellation fee. (5:30 pm Monday-Thursday)

Cancelling same day or not showing up to your scheduled new patient chiropractic appointment results in a $250 no show fee.

Cancelling same day or not showing up to your scheduled chiropractic appointment results in a $50 no show fee.

Cancelling same day or not showing up to your scheduled chiropractic exam appointment results in a $100 no show fee.

Cancelling same day or not showing up to your scheduled massage appointment results in paying THE ENTIRE FEE for the massage.

Cancelling same day or not showing up to your scheduled craniosacral therapy massage appointment results in paying THE ENTIRE FEE for the craniosacral therapy massage.

Office policy is for all patients to keep a credit/debit card on file.

Patients who prefer to pay with cash or check are still required to keep a card on file.

When a no-show fee is added to your account, we will reach out to you via call, text, and email to inform you.

We will process your card for the appropriate fee by the end of the next business day.

**Patients on an auto accident lien, or using med-pay will still be charged the fee for a missed appointment, and will not get reimbursed from the third-party payer.

Please initial and sign below to acknowledge you understand this policy.

Keeping a credit/debit card on file is necessary in the event I am responsible for a no-show fee.
I understand my credit/debit card on file will be charged the appropriate fee by the end of the next business day.
I am aware that in the event I need to change or cancel a scheduled appointment and I do not call, text, or email [email protected] at least 24 hours before my scheduled appointment I am subject to a $250 FEE FOR NEW PATIENT APPOINTMENT
I am aware that in the event I need to change or cancel a scheduled appointment and I do not call, text, or email [email protected] at least 24 hours before my scheduled appointment I am subject to a $50 FEE FOR CHIROPRACTIC APPOINTMENT
I am aware that in the event I need to change or cancel a scheduled appointment and I do not call, text, or email [email protected] at least 24 hours before my scheduled appointment I am subject to a $100 FEE FOR CHIROPRACTIC EXAM
I am aware that in the event I need to change or cancel a scheduled appointment and I do not call, text, or email [email protected] at least 24 hours before my scheduled appointment I am subject to PAYMENT IN FULL FOR MASSAGE APPOINTMENT
I am aware that in the event I need to change or cancel a scheduled appointment and I do not call, text, or email [email protected] at least 24 hours before my scheduled appointment I am subject to PAYMENT IN FULL FOR CRANIOSACRAL THERAPY APPOINTMENT

Assignment of Benefits

ASSIGNMENT OF BENEFITS and RELEASE OF AUTHORIZATION

I hereby authorize my insurance company to make payments to Elizabeth S. Hoefer, D.C., or Hoefer Well Connected Chiropractic Corporation for chiropractic or massage services rendered to me or my dependents, if applicable. Should my insurance carrier deny Well Connected Chiropractic payment, I understand that I am financially responsible for all charges. I authorize Well Connected Chiropractic to release any and all of my records to my insurer, or any third party payer, legally responsible for the payment of chiropractic or massage. I certify that the information provided or to be provided by me is correct and complete to the best of my knowledge. It is my responsibility to update any and all personal, insurance, and health information. I agree that a photocopy of this assignment shall serve in lieu of the original.

Please initial, indicating you understand and authorize your insurance company to make payments as outlined above:

Your Initials

HIPAA Notice

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 Well Connected 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 2003, and any alterations or amendments made hereto will expire seven years after the date upon which the record was created.

My initials and signature (bottom of form) confirm that I have received a copy of this notice.

Please list other people (i.e. spouse, child, friend, personal trainer, attorney, massage therapist, acupuncturist, nutritionist) with whom you authorize Well Connected Chiropractic to discuss your chiropractic care and health information.

Please initial, acknowledging you've read and understand the above HIPAA policy

Enter initials here

About Medicare

ABOUT MEDICARE COVERAGE

The government’s Medicare program only pays Doctors of Chiropractic (DCs) for limited services. If your needed Chiropractic Adjustment (manipulation treatment) meets Medicare’s rules, they will usually pay for it. There are three categories of Medicare services: 1.) non-covered 2.) always covered, and 3.) perhaps covered.

NON-COVERED

According to existing Medicare law, most of the available services in our office are NON-COVERED. Hopefully, the U.S. Congress will change that someday and treat Doctors of Chiropractic like all other doctors. Until then:

Examples of Non-Covered Services

All Services Other than Chiropractic Adjustments:

· Office Visits- to evaluate and manage, re-evaluate, advise, or

counsel.

· Physiotherapy- such as massage, traction, electrical stimulation, neuromuscular re-education, etc.

· X-rays, Laboratory, Supplies, Vitamins, etc.

Various Chiropractic Adjustments:

· Adjustment on an area other than the spine- (to the shoulder, arm, leg, etc.)

· Maintenance Care- you are stable and not making any more improvement.

· Wellness Care- to promote better health.

NON-Covered items will appear on your insurance claim form.

They will show as a Medicare NON-Covered service like this: “72010-GY”. The “72010” code is for an x-ray. The “–GY” code means that it is not-covered, allowing your service to go through the Medicare system. After denial by Medicare, it can then go onto your other insurance. If you have Medigap insurance (also known as Medicare Secondary or Supplemental insurance), they will pay according to the terms of your contract.

ALWAYS COVERED

A Typical example of a Medicare COVERED service (or clinically needed) is when you are in much pain due to a bad spinal condition. You should also expect Medicare to cover and pay for your rehabilitation as long as you are improving. When you have a COVERED chiropractic spinal adjustment (manipulation treatment), it will be shown on your Medicare claim form and payment reports as either “98940”, “98941”, or “98942”.

PERHAPS COVERED

Your Chiropractic Adjustment must be clinically needed according to Medicare. If Medicare thinks your condition is not “Medically Necessary”, they won’t pay. If we know or believe that Medicare will not pay for your Chiropractic Adjustment due to any rules that they might have, we will let you know. We will give you a special Medicare form known as the Advance Beneficiary Notice (ABN).

STATEMENT OF UNDERSTANDING

I understand that I am personally financially responsible for all Medicare NON-covered services. I also understand that there could be times when my chiropractic adjustments might not be covered. If so, my doctor will let me know. I am also responsible for any annual deductibles or applicable copayments as required by Medicare.

Please initial acknowledging receipt of the above Medicare Information

Initials Indicating I read and Understand Medicare Information Outlined in this Form

By signing below, I hereby authorize that all of the information stated about myself is truthful, and that I have read and agree to the above statements outlined in this form:

Initial Patient Record

Financial Agreement

No Show Policy

Assignment of Benefits

HIPAA Notice

About Medicare

Patient Name

Signature of Patient or Person Acting on Patients Behalf

Clear

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