New Patient Intake & Consent Forms

This Patient Communication Consent Agreement (the "Agreement") is entered into between Greater Chiropractic, LLC and those affiliated with Greater Chiropractic (i.e. biller, staff, doctor, etc.), hereinafter referred to as the "Chiropractic Practice," and the patient identified in this form, hereinafter referred to as the "Patient." This Agreement pertains to the communication methods used by the Chiropractic Practice to contact the Patient regarding scheduling, care plan information, payment, missed appointments, and other relevant matters.

Patient Consent: By signing below, the Patient acknowledges and agrees to the following:

1. Communication Methods: The Patient consents to be contacted by Greater Chiropractic via text message, email, regular mail and phone calls (including automated and prerecorded calls) to the phone numbers and email address provided in this form. These communications will be related to, but not limited to, appointment scheduling, care plan information, payment reminders, and notifications of missed appointments.
2. Frequency of Communication: The Patient understands that communication may occur on a regular basis, as necessary to provide appropriate chiropractic care and manage administrative matters.
3. Privacy: Greater Chiropractic will take all necessary measures to protect the privacy and security of the Patient's personal information, as required by applicable laws and regulations.
4. Opt-Out: The Patient has the right to opt out of receiving communications at any time. To do so, the Patient may notify the practice in writing or via email at greaterchiromi@gmail.com.
5. Additional Terms: This Agreement does not affect any other agreements or policies that the Patient has with Greater Chiropractic, including but not limited to the Patient Privacy Policy and Consent for Treatment.

By signing below, the Patient acknowledges that they have read and understood this Patient Communication Consent Agreement and voluntarily consent to be contacted by the Chiropractic Practice through the specified communication methods. This Agreement may be reviewed and updated as needed, and any changes will be communicated to the Patient in advance.

Protecting the privacy of your personal health information is very important to us. Disclosure of your protected health information without authorization is strictly limited to defined situations that include emergency care, quality insurance activities, public health, and research and law enforcement activities. Any other disclosure for the purposes of treatment payment or practice operations will be made only after obtaining your consent. You may request restrictions on your disclosures. You may inspect and receive copies of your records within 30 days of your request. You may request to view changes to your records. In the future, we may contact you for appointment reminders, announcements and to inform you about our practice and its staff.

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand this information can be used to: conduct, plan and direct my treatment and follow up with multiple providers that may be treating me, obtain payment from third party payers and conduct normal health care operations such as quality assessments and physician's certifications. The complete HIPAA manual is in the waiting room for my review. I have read and understand your Notice of Privacy Practices. A more complete description may be requested.

It is important that you understand, results are not guaranteed, and there is no promise to cure. As with all types of health care interventions there are some risks to care, but please rest assured that all precautionary measures, diagnostic tests, and orthopedic testing will be done and with consent, performed to minimize any risks. These risks include, but are not limited to: muscle spasms, aggravating and/or temporary increase in symptoms, lack of improvement of symptoms, burns from E. Stim and from hot or cold therapies, fractures, disc injuries, strokes, dislocations, strains, and sprains.

With respect to strokes, there is a rare but serious condition known as an "arterial dissection" that typically is caused by a tear in the inner layer of the artery that may cause the development of a clot with the potential to lead to stroke. The best available scientific evidence supports the understanding that chiropractic adjustment does not cause a dissection in a normal, healthy artery. Disease processes, genetic disorders, medications, and vessel abnormalities may cause an artery to be more susceptible to dissection. The reported association between chiropractic visits and stroke is exceedingly rare and is estimated to be related in one in one million to one in two million cervical adjustments.

It is also important that you understand there are treatment options available for your condition other than chiropractic procedures. You have the right to a second opinion and to secure other opinions about your circumstances and health care as you see fit.

We do not offer to diagnose or treat any condition other than vertebral subluxations. However if during the course of a chiropractic spinal evaluation, we encounter non-chiropractic findings we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend you seek a specialist in that field. Our only practice objective is to eliminate vertebral subluxation. By signing below you are authorizing the treatment and understanding the information offered above. Your signature also allows our office to release any information offered above and consent to treatment based on the doctor's recommendations. By signing below you understand that this is not a medical diagnostic center but a chiropractic & wellness clinic in which the main focus is to correct spinal subluxations and to reduce pain and improve quality of life so you can function better. Our staff does not diagnose severe illnesses, disease or any physical or mental condition, nor do they prescribe medication.

Dear Patient:

You have selected "INSURANCE ASSIGNMENT" as the method of choice to take care of your financial obligation with this office. It is important that you realize that in this office, we offer the option of "INSURANCE ASSIGNMENT" strictly as a courtesy to our patients, and, as such, our patients must understand and agree to the following:

1. That you are considered a cash patient until you bring in completed insurance forms, and this office qualifies and accepts your coverage.
2. That you are ultimately responsible for full payment for any and all services rendered.
3. That you will pay all deductibles in full.
4. That co-insurance must be paid at the time of service.
5. That if your carrier has not paid a claim within 120 days of submission, you are responsible to take an active part in the recovery of your claim and that after 150 days you will be responsible for payment in full for any outstanding balance.
6. That, in the event you discontinue your program of care prior to the doctor's consent, you are responsible for payment in full of any outstanding balance, and the courtesy of insurance assignment is immediately discontinued.

This insurance assignment policy must be followed. We ask that you sign this form as acknowledgement that our policy was explained to you, that you understand it and that you accept full financial responsibility.