Confidential Patient Information


 

Confidential Patient Information

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Due to changes in health insurance fees, patient self billing has become a much more cost-effective way for you, the patient, to get reimbursement for your care. Self billing allows us to keep our fees low so you can get the care you need without any added cost. Therefore, our policy is that all payment is due at the time of service and bills will no longer be sent to your insurance provider. Statements will be provided for individuals to submit their own bills ensuring that as your insurance provider pays for your care, they will send the reimbursement check directly to you.

All charges are due when services are rendered…

Why Chiropractic? People go to Chiropractors for a variety of reasons. Some go for symptomatic relief of pain or discomfort (Relief Care). Others are interested in having the cause of the problem as well as the symptoms corrected and relieved (Corrective Care). Your doctor will weigh your needs and desires when recommending your treatment program.

Relief care is that care necessary to get rid of your symptoms or pain, but not the cause of it. It is the same as drying a floor that was getting wet from a leak, but not fixing the leak.

Corrective care differs from relief care in that its goal is to get rid of the symptoms or pain while correcting the cause of the problem. Corrective care varies in length of time, but is more lasting.

Please mark an X on the diagram below where your problems are

Body Diagram
 
Check any of the following you have had in the six months:
 
 
Are you pregnant?
 
Patient Consent for Release of Care and Records

With my consent, Upper Cervical Health Centers Of America to release me from care and may close my case file protected under the health information (PHI) to carry out treatment, payment and healthcare options(TPO). Please refer to Upper Cervical Health Centers of America Notice of Privacy for a more complete description of such uses and disclosures.

I have the right to review the Notice of Privacy Practices prior to signing this consent. UCHCA reserves the right to revise its Notice of Privacy Rights at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to UCHCA.

With my consent, UCHCA may call my home or other designated location and leave a message on voice mail or in person in reference to any item that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my chiropractic care.

With my consent, UCHCA may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements.

By signing this form, I am consenting to Upper Cervical Health Centers of America's release me from care and may close my case file. I am also requesting a refund of the balance of my care plan, in which I understand will be refunded to me within 30 days upon signing and dating this form.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, Upper Cervical Health Centers Of America may decline to provide treatment, refund, and/or release of patient forms and case file to me or any other provider.

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Document name: Confidential Patient Information
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Timestamp Audit
May 21, 2024 1:29 pm GMTConfidential Patient Information Uploaded by Dr. Scott Baker - [email protected] IP 103.138.125.198
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