Just For The Health Of It – Patient IntakePart 1 - Policy FormsPayment Consent(Required) I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that Just For the Health of It will prepare any necessary reports and forms to assist me in making collections from the insurance company and that any amount authorized to be paid directly to Just For the Health of It will be credited to my account on receipt. However, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. If it becomes necessary to effect collections of any amount owed on this or subsequent visits the undersigned agrees to pay for all costs and expenses including reasonable attorney fees. I hereby authorize the doctor to release information necessary to secure payment of benefits.Are you under or over 18?(Required) Adult MinorTreatment Consent(Required) I the undersigned being 18 years of age or older, give my consent to examination and treatment as deemed necessary and acceptable, understand that there are risks involved in the treatment of the spine and associated structures.Minor Treatment Consent(Required) I the undersigned parent/or person having legal custody/guardianship of the above named minor, do hereby authorize and consent to any x-ray, examination and chiropractic diagnosis or treatment, which is deemed advisable by a licensed chiropractor of this office. This authorization shall remain in effect until revoked by the undersigned parent/guardian.Patient Signature(Required)Parent/Guardian Signature(Required)Digital Communication PolicyDigital Communication Policy By consenting you are agreeing to receive email, newsletters, text messages for appointment reminders and other healthcare communications / promotions or product updates: Patients in our practice may be contacted via phone, email and/or text messaging to remind you of an appointment, to obtain feedback on your experience with our healthcare team, and to provide general health reminders/promotions/deals and other information.My Preferred Communication Method(Required) Text Email Phone CallPhone(Required)Email(Required) Name(Required) First Last Signature(Required)November 28, 2023 at 8:45 amHealth PolicyHipaa Consent(Required) This notice of Privacy Practices describes how we may use and disclose your PHI to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your PHI. “PHI” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical and/or mental health or condition and related health care services. Uses and Disclosures of PHI: Your PHI may be used and disclosed by your physician, our office staff and others of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law. Treatment: We will use and disclose your PHI to provide, coordinate, or manage your health care and any related services. This includes the coordination of management of your health care with a third party. For example, we would disclose your PHI, as necessary, to your primary care physician that provides care to you. For example, your PHI may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. Payment: Your PHI will be used, as needed, to obtain payment for your health care services. For example, obtaining prior approval for chiropractic or massage treatment may require that your relevant PHI be disclosed to the health plan or the health plan’s third party administrator to obtain approval for the treatment. Healthcare Operations: We may use or disclose, as needed, your PHI in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your PHI to medical students that see patients in our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment. We may use or disclose your PHI in the following situations without your authorization. These situations as Required By Law include: Public Health Issues, Communicable Diseases, Health Oversight, Abuse or Neglect. Food and Drug Administration requirements, Legal Proceedings, Law Enforcement, Coroners, Funeral Directors, Organ Donation, Research, Criminal Activity, Military Activity, National Security, Workers Compensation, Inmates required uses and disclosures. Under the Law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500. Other Permitted and Required Uses and Disclosures: Will be made only with your consent, authorization, or opportunity to object unless required by law. You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization. Your Rights: The following is a statement of your rights with respect to your PHI. You have the right to inspect and copy your PHI. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and PHI that is subject to law that prohibits access to PHI. You have the right to request a restriction of your Protected Health Information: This means that you may ask us not to disclose any part of your PHI for the purpose of treatment, payment, or healthcare operations. You may also request that any part of your PHI may be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If the physician believes it is in your best interest to permit use and disclosure of your PHI, your PHI will not be restricted. You then have the right to use another Healthcare Professional. You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically. You may have the right to have your physician amend your PHI. If we deny your request for an amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected information. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice. Complaints: You may complain to use or by the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. This notice was published and becomes effective on/or before April 14, 2013. We are required by law to maintain the privacy of, and provide individuals with this notice of our legal duties and privacy practices with respect to PHI. If you have any questions about this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at 360-241-6630.Signature below is only acknowledgement that you have received this notice of our Privacy Practices.(Required)Name(Required) First Last November 28, 2023 at 8:45 amFinancial PolicyFinancial Consent(Required) It is the policy of Olsen Chiropractic LLC dba Just For The Health Of It, that all care and services rendered are charged directly to you, the patient, and you are ultimately responsible for all payments, regardless of whether or not this office accepts insurance assignment. Olsen Chiropractic will handle the billing details with the insurance company(s) on your behalf. Olsen Chiropractic will not accept assignments with any insurance company. However, Olsen Chiropractic, at the sole discretion of Dr. Cara Olsen, may wait for payment until your particular case is settled provided that you obtain an attorney who is willing to protect the fees and charges from Olsen Chiropractic. Furthermore, the attorney must be willing, and signs a document stating he/she will protect the fees, and charges of Olsen Chiropractic. Olsen Chiropractic may file a medical lien as part of our billing and collection process. All payments are expected at the time of service or at the end of each week. Patient balances may not exceed $200.00 at any time, or professional services may be terminated. A financial charge of one percent (twelve percent annually)-minimum $2.00 charge and subject to change-will be assessed for my account when in excess of the amount stated above. The financial change will be assessed at or near the time of the billing cycle at the end of each month. This office will bill your insurance company for you on a regular basis. I understand that my insurance policy is a contract between the insurance company and myself. Therefore, I am ultimately responsible for payment of all care and services rendered to me by Olsen Chiropractic. A non-sufficient funds charge (NSF), of no less than $20.00 and subject to change will be charged for each check or credit card transaction returned as NSF. I also acknowledge and understand that if I suspend or terminate my care and treatment, any fees and charges for professional services rendered for me will be immediately due and payable. In the event of a delinquency and or a dispute of my account and/or if my case is turned over to collections for non-payment, I am responsible for all collection and legal fees accrued as a result of the action(s).My signature below verifies that I have been informed of and that I fully understand, and am in agreement with the financial policy of Olsen Chiropractic.(Required)Name(Required) First Last November 28, 2023 at 8:45 amConsent(Required) To the best of my knowledge, the information I entered in this entire intake is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever has a change in health.
