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Privacy Policy | Terms of Service
Thank you for choosing Durango Chiropractic Associates for your medical needs. We are committed to providing you with the highest quality healthcare. We ask that you read and confirm the following before continuing.
Patient Financial Responsibilities
The patient (or patient's guardian, if a minor) is ultimately responsible for payment for treatment and care.
We will bill your insurance for you. However, you are required to provide the most correct and updated insurance information.
You are responsible for payment of copays, coinsurance, deductibles, and any procedures or treatment not covered by your plan.
Copays, coinsurance, deductibles, and non-covered items are due at time of service.
If your insurance requires a referral from your PCP, it is your responsibility to obtain it. If we don't have one and your claim is denied, you will be responsible for the full balance.
If you are going through a personal injury case and your auto insurance or attorney doesn't pay, you will be responsible for the remaining balance.
By signing below, you authorize assignment of financial benefits directly to Durango Chiropractic for services rendered as allowable under standard third-party contracts, and acknowledge you are financially responsible for charges not covered by this assignment.
Informed Consent for Chiropractic Treatment
I hereby request and consent to the performance of chiropractic procedures, including a comprehensive exam, diagnostic testing, physical therapy modalities, adjustments, or manipulation recommended by the doctors at Durango Chiropractic. I understand that, as with any healthcare procedure, there are certain complications that may arise during a chiropractic adjustment. Although rare, these include but are not limited to muscle sprain/strain, dislocations, fractures, and costovertebral strains and separations. Some neck manipulations have been associated with injuries to the arteries in the neck, potentially contributing to serious complications including stroke.
Although patients are screened for candidacy to the best of our ability, the doctor cannot anticipate every risk or complication. The doctor will act in the best interest of the patient based on the facts known at the time. I understand I can terminate treatment at any time.
I understand there are risks involved with chiropractic therapy, that the above information I've provided is true and accurate, and that I will inform my practitioner of any changes in my health. I understand my records are confidential except in cases involving abuse, neglect, or harm to others, as outlined in the Notice of Privacy Practices provided to me. I take full responsibility for alerting my chiropractor to any condition that would affect this therapy, and confirm I have not been told by another provider that I should not receive chiropractic care.
I understand this treatment is intended to manage certain conditions but has no guarantee of success or effectiveness. I understand that false or misleading information I provide, or failure to follow post-care instructions, may lead to undesired results, and I waive liability in such cases.