Our office is required by the Federal HIPAA Laws to have you sign whether you desire to have your PHI discussed with a family member or friend. If you authorize our office to speak with a family member or friend please indicate the name of the person, relationship to you and what may be discussed.

If you have any aspects of your PHI that you do not want disclosed, please list the specific aspects of your PHI below that you wanted “restricted.” This authorization may be revoked by you at any time, by advising our office (privacy officer) of this revocation in writing.

If you choose not to sign this authorization, this will not have any adverse effects on your treatment, eligibility for benefits, enrollment, or payment.

Protect Health Information (PHI) Authorization

The Health Insurance Portability and Accountability Act (HIPAA) require that all health care providers comply with patient privacy laws. Patient confidentiality and privacy applies to any protected health information (PHI). Federal laws now require signed and dated authorization from patients in several aspects of patient care, transmission of medical information, confidentiality, and patient rights relating to their medical records.

In order for this authorization to be valid you must sign, date and indicate an expiration date or event on your authorization. The privacy rules require that the doctor post the notice in a prominent place.

Privacy Notice

I acknowledge that Chiropractic Neurology Center (CNC) located at 1225 E. Wardlow Rd. Long Beach, CA 90807, has represented me with a copy of their privacy practices and I have been able to read the practice policies notice that has been provided.

This notice explains how my protected health information (PHI) may be used and what Chiropractic Neurology Center's responsibilities are regarding my privacy rights. I have been allowed to request a printed sheet of Chiropractic Neurology Center's privacy notice.

Please indicate whether you are the parent or legal guardian of the patient or minor.

I hereby request and consent to the performance of a chiropractic neurology examination, including but not limited to diagnostic x-rays on me, or the patient named below (for whom I am legally responsible). This consent is made to be performed by on of the Doctor(s) of Chiropractic named above, and/or other licensed doctors of chiropractic and support staff who now, or in the future, provide treatment to me while employed by Chiropractic Neurology Center.

I understand and I am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment, including by not limited to; fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctors to be able to anticipate and explain all the risks and complications. I wish to rely on the doctors to exercise judgment during the entire course of treatment, based upon the facts known at the time of treatment, that is in my best interest.

I further request and consent for various modes of physical therapy and chiropractic neurology procedures/techniques performed by the chiropractor named above, and/or other licensed doctors of chiropractic, who now or in the future may provide treatment while employed by Chiropractic Neurology Center, working or associated with, or serving as a backup in consultation with the doctor of chiropractic named above, including those working at the clinic or office listed above or any other office, hospital, clinic, or location.

Chiropractic Neurology Center is required by federal HIPPA laws to have your signed and dated permission to access your PHI (Protected Health Information). This authorization to allow other healthcare providers access to your PHI for diagnosis and treatment may be revoked by you at any time, by advising our office of this revocation in writing.

I have read and understand the above consent. I have also had an opportunity to ask any and all questions about this consent, and by signing below I agree to the treatment and/or procedures recommended by any and all providers at Chiropractic Neurology Center. I intend this consent to cover the entire course of treatment for my present condition and for any future conditions for which I seek treatment.

Chiropractic Neurology Center is committed to providing quality care and service to all our patients. Your understanding of our financial policies is important to our professional relationship. Please take a moment to read through this document and fully understand your responsibility as a patient, initial each policy, then sign and date below.

Self-Pay/CASH Patient Services

I understand that if I am a CASH Patient or the office is not a Network Provider of my current insurance policy; I am responsible for the full Cash Patient Service amounts. I understand Chiropractic Neurology Center will expect payment in full for services rendered at time of service.

Insurance Information

I understand that as a patient, it is my responsibility to supply the current and correct insurance card at time of service, or to update any incorrect information on file. Failure to provide this information may result in service charges being fully my responsibility.

Insurance Deductibles/Coinsurance/Co-payments/Non-Covered Services

I understand that all required patient responsibility amounts applied by my insurance company after processing of claims are my financial responsibility. These amounts are not negotiable, and an estimate of balance due may differ from the final insurance processing. Furthermore, I understand that services not covered by my insurance policy will fully be my responsibility and will either be paid in full at time or service or after insurance has processed my claim. I understand Chiropractic Neurology Center will expect payment in full of the estimated patient responsibility at time of service, or after my claim has fully processed by insurance. Any overpayment will result in a credit to my account for future services.

Referrals & Authorizations

I understand that it is ultimately the responsibility of myself as the patient, to verify if any referral or authorization is required by my insurance policy before any services are rendered by Chiropractic Neurology Center. I understand that Chiropractic Neurology Center will do their best to inform me of such requirements prior to services rendered, but ultimately if services are denied for such requirements, I will be held financially responsible for said service(s).

Minors

I understand services rendered to minor patients, I as the Parent/Guardian am responsible for all payments at time of service or applied as patient responsibility resulting from service rendered.

Late Cancellation/No Show Policy

I understand that if I do not cancel any scheduled appointment at least 24 hours in advance, or no show a scheduled appointment I will be charged a Late Cancellation Fee/No Show Fee. These fees are based on the services scheduled and vary. A list of these fees will be readily available by the front desk staff at my request. Habitual Late Cancellation/No Show of appointments will result in dismissal from the practice.

Delinquent Account

I understand it is my financial obligation as a patient that I must pay in full or settle any balances prior to any additional services being scheduled/rendered. Failure to bring my account current within 90 days of statement, can result in my balance being sent to a collection agency, and/or being dismissed from the practice.

I have read and agree to all financial policies of Chiropractic Neurology Center, and understand I am bound to these terms of my financial obligation as a patient. I also understand that Chiropractic Neurology Center has the right to amend these policies at any time.