OFFICE POLICY REGARDING PAYMENT & INSURANCE ASSIGNMENT
In order to establish optimal relations with our patients and avoid misunderstanding and confusion regarding our payment policies, our staff is trained to consistently inform you of the financial payment policies of this office. Payment is required for all services at the time they are rendered unless you are in a prepaid plan in which we participate. For those patients, applicable deductibles and co-payments will be collected. We accept payment in the form of cash, check, debit cards and/or credit cards. If you issue our office a NSF check, a return check fee will be assessed. Our office may accept your insurance assignment. As soon as your coverage is verified by the responsible party, and if we accept your insurance assignment, we will file your claims and assist you in every way we can. However, it must be understood that the contract is between you and your insurance company and you are fully responsible for any charges not paid by your insurance company. All insurance companies have their own
Usual/Reasonable/Customary guidelines and we have tried to establish a medium that is fair to all parties involved; however, any disputes in this matter are between you and your insurance company.
OUR OFFICE POLICY REGARDING INSURANCE ASSIGNMENT:
1. By accepting your insurance assignment, we have to wait for payment, this courtesy may be withdrawn if we determine circumstances warrant it.
2. If you discontinue care without the doctor’s consent, the balance of your account is due and payable in full immediately. even if your insurance claims have been filed. {If the insurance company pays on your claims,
you will be refunded any credit that is on your account once we have received payment in full on all of your claims.)
3. Your insurance company should pay within thirty (30) days of your claim being filed. If your insurance company has not paid your claims within sixty (60) days of your claims being filed, you must pay the balance due and be reimbursed by your insurance company when and if it pays.
4. We will attempt to bill your insurance claims on thirty (30) day cycles to your insurance company, or more frequently, as long as you are receiving chiropractic care in this office. Once we receive payment for your insurance claims, we will bill you for any balance that may be due at that time.
5. Your responsibility is to pay your deductible, co-pays, co-insurance, and/or any amount not covered and/or not.. approved by your insurance company at each office encounter. As your healthcare provider, I want to provide
you with the best care possible. There may be certain routine services that I feel are necessary for the maintenance of your good health that are not covered and/or not approved by your health insurance contract.
6. You are required to sign an “Assignment, Authorization & Lien” form to pay the physician and any other documents required by your insurance company or our office on your initial office visit.
7. Our office DOES NOT GUARANTEE that your insurance company will pay. We will make every attempt, at the beginning of your health care, to receive verification of your policy benefits, however, we DO NOT GUARANTEE THEM. If for any reason, your insurance claim is denied. you are responsible for the full amount of your bill.
8. Our office WILL NOT enter into a dispute with your insurance company over your claim. This is your claim and your responsibility and obligation.
I hereby acknowledge receipt of goods and services as received pertinent to my history, in the amount of the total hereon. Your signature (on the patient form) signifies your understanding and willingness to comply with this policy and we may accept your insurance assignment.
CONSENT TO USE PHI
ACKNOWLEDGEMENT FOR CONSENT TO USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
Use and Disclosure of your Protected Health Information Your Protected Health Information will be used by Discover Chiropractic, or may be disclosed to others for the purposes of treatment, obtaining payment, or supporting the day-to-day health care operations of this office. Notice of Privacy Practices You should review the Notice of Privacy Practices for a more complete description of how your Protected Health Information may be used or disclosed. It describes your rights as they concern the limited use of health information, including your demographic information, collected from you and created or received by this office. I have received a copy of the Notice of Patient Privacy Policy.
Requesting a Restriction on the Use or Disclosure of Your Information
• You may request a restriction on the use or disclosure of your Protected Health Information.
• This office may or may not agree to restrict the use or disclosure of your Protected Health Information.
• If we agree to your request, the restriction will be binding with this office. Use or disclosure of protected information in violation of an agreed upon restriction will be a violation of the federal privacy standards.
Notice of Treatment in Open or Common Areas
Please be aware that in open or common areas others may overhear your conversations. Please tell the staff if you need to provide any information in private.
Revocation of Consent
You may revoke this consent to the use and disclosure of your Protected Health Information. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected.
EMAIL & SMS/TEXT MESSAGING CONSENT
I hereby consent and state my preference to have my physician and other staff communicate with me by email or standard SMS/text messaging, in addition to or to replace leaving phone messages, regarding various aspects of my health care, which may include, but shall not be limited to, test results, appointments, and billing. I understand that email and standard SMS/text messaging are not confidential methods of communication and may be insecure. I further understand that, because of this, there is a risk that email and standard SMS/text messaging regarding my medical care might be intercepted and read by a third party.
I give my permission to leave appointment reminders and my private health information at the contact information provided in the patient form.
Male/Female Consent to X-ray
By agreeing to the terms of service, I authorize Discover Chiropractic, and/or physicians at Discover, and/or their staff, and/or whomever they may designate as their assistants to take x-rays.
FEMALE CONSENT TO X-RAY / PREGNANCY RELEASE
By agreeing to the terms of service, I hereby notify all concerned that I neither suspect nor know positively at this time that I may be or am pregnant. I release Discover Chiropractic, and/or physicians at Discover, and/or their staff from any and all damages arising from any and all procedures of a diagnostic or treatment nature with reference to possibility of pregnancy. I hereby release Discover Chiropractic, and/or physicians at Discover, and/or his staff, and/or whomever he may designate as his assistants from any and all liability. I hereby grant permission to Discover Chiropractic, and/or physicians at Discover, and/or their staff, and/or whomever they may designate as their assistants to take x-rays.
Informed Consent
CHIROPRACTIC
It is important to acknowledge the difference between the health care specialties of Chiropractic, Osteopathy, and Medicine. Chiropractic health care seeks to restore health through natural means without the use of medicine or surgery. This gives the body maximum opportunity to utilize its inherent recuperative powers. The success of the Chiropractic Doctor’s procedures often depends on environment, underlying causes, physical and spinal conditions. It is important to understand what to expect from Chiropractic health care services.
ANALYSIS
A Doctor of Chiropractic conducts a clinical analysis for the express purpose of determining whether there is evidence of Vertebral Subluxation Syndrome (VSS) or Vertebral Subluxation Complexes (VSC). When such VSS and VSC complexes are found, chiropractic adjustments and ancillary procedures may be given in an attempt to restore spinal integrity. It is the Chiropractic premise that spinal alignment allows nerve transmission throughout the body and gives the body an opportunity to use its inherent recuperative powers. Due to the complexities of nature, no doctor can promise you specific results. This depends upon the inherent recuperative powers of the body.
DIAGNOSIS
Although Doctors of Chiropractic are experts in Chiropractic diagnosis, the VSS and VSC, they are not internal medical specialists. Every Chiropractic patient should be mindful of his/her own symptoms and should secure other opinions if he/she has any concern as to the nature of his/her total condition. Your Doctor of Chiropractic may express an opinion as to whether or not you should take this step, but you are responsible for the final decision.
INFORMED CONSENT FOR CHIROPRACTIC CARE
I hereby request and consent to the performance of chiropractic treatments {also known as chiropractic adjustments or chiropractic manipulative treatments) and any other associated procedures: physical examination, tests, diagnostic x-rays, physiotherapy, physical medicine, physical therapy procedures, etc. on me by the doctor of chiropractic named above and/or other assistants and/or
licensed practitioners. I understand, as with any health care procedures, that there are certain complications, which may arise during chiropractic treatments. Those complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, Homer’s syndrome, diaphragmatic paralysis, cervical myelopathy and costovertebral strains and separations. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to complications including stroke. I do not expect the doctor to be able to anticipate all risks and complications, and I wish to rely upon the doctor to exercise judgment during the course of the procedure(s) which the doctor feels at the time, based upon the facts then known, that are in my best interest. I have had an opportunity to discuss the nature, purpose and risks of chiropractic treatments and other recommended procedures.
I have had my questions answered to my satisfaction. I also understand that specific results are not guaranteed. If there is any dispute about my care, I agree to a resolution by binding arbitration according to the American Arbitration
Association guidelines. I have read (or have had read to me) the above explanation of the chiropractic treatments. I state that I have been informed and weighed the risks involved in chiropractic treatment at this health care office. I have decided that it is in my best interest to receive chiropractic treatment. I hereby give my consent to that treatment. I intend for this consent to cover the entire course of treatment
for my present condition(s) and for any future conditions(s) for which I seek treatment.
RESULTS
The purpose of Chiropractic services is to promote natural health through the reduction of the VSS or VSC. Since there are so many variables, it is difficult to predict the time schedule of efficacy of the Chiropractic procedures. Sometimes the response is phenomenal. In most cases there is more gradual, but quite satisfactory response. Occasionally, the results are less than expected. Two or more similar conditions may respond differently to the same Chiropractic care. Many medical failures find quick relief through Chiropractic.
In turn, we must admit that conditions which do not respond to Chiropractic care may come under the control or be helped through medical science. The fact is that the science of Chiropractic and medicine may never be so exact as to provide definite answers to
all problems; both have taken great strides in alleviating pain and controlling disease.
3. EMBEDDED CONTENT
Pages on this site may include embedded content, like YouTube videos, for example. Embedded content from other websites behaves in the exact same way as if you visited the other website.
These websites may collect data about you, use cookies, embed additional third-party tracking, and monitor your interaction with that embedded content, including tracking your interaction with the embedded content if you have an account and are logged-in to that website. Below you can find a list of the services we use:
The Facebook page plugin is used to display our Facebook timeline on our site. Facebook has its own cookie and privacy policies over which we have no control. There is no installation of cookies from Facebook and your IP is not sent to a Facebook server until you consent to it. See their privacy policy here: Facebook Privacy Policy .
We use the Twitter API to display our tweets timeline on our site. Twitter has its own cookie and privacy policies over which we have no control. Your IP is not sent to a Twitter server until you consent to it. See their privacy policy here: Twitter Privacy Policy .
YOUTUBE
We use YouTube videos embedded on our site. YouTube has its own cookie and privacy policies over which we have no control. There is no installation of cookies from YouTube and your IP is not sent to a YouTube server until you consent to it. See their privacy policy here: YouTube Privacy Policy.
4. COOKIES
This site uses cookies – small text files that are placed on your machine to help the site provide a better user experience. In general, cookies are used to retain user preferences, store information for things like shopping carts, and provide anonymized tracking data to third party applications like Google Analytics. Cookies generally exist to make your browsing experience better. However, you may prefer to disable cookies on this site and on others. The most effective way to do this is to disable cookies in your browser. We suggest consulting the help section of your browser.
NECESSARY COOKIES (ALL SITE VISITORS)
- cfduid: Is used for our CDN CloudFlare to identify individual clients behind a shared IP address and apply security settings on a per-client basis. See more information on privacy here: CloudFlare Privacy Policy.
- PHPSESSID: To identify your unique session on the website.
NECESSARY COOKIES (ADDITIONAL FOR LOGGED IN CUSTOMERS)
- wp-auth: Used by WordPress to authenticate logged-in visitors, password authentication and user verification.
- wordpress_logged_in_{hash}: Used by WordPress to authenticate logged-in visitors, password authentication and user verification.
- wordpress_test_cookie Used by WordPress to ensure cookies are working correctly.
- wp-settings-[UID]: WordPress sets a few wp-settings-[UID] cookies. The number on the end is your individual user ID from the users database table. This is used to customize your view of admin interface, and possibly also the main site interface.
- wp-settings-[UID]:WordPress also sets a few wp-settings-{time}-[UID] cookies. The number on the end is your individual user ID from the users database table. This is used to customize your view of admin interface, and possibly also the main site interface.
5. WHO HAS ACCESS TO YOUR DATA
If you are not a registered client for our site, there is no personal information we can retain or view regarding yourself.
If you are a client with a registered account, your personal information can be accessed by:
- Our system administrators.
- Our supporters when they (in order to provide support) need to get the information about the client accounts and access.
6. THIRD PARTY ACCESS TO YOUR DATA
We don’t share your data with third-parties in a way as to reveal any of your personal information like email, name, etc. The only exceptions to that rule are for partners we have to share limited data with in order to provide the services you expect from us. Please see below:
ENVATO PTY LTD
For the purpose of validating and getting your purchase information regarding licenses for the our theme, we send your provided tokens and purchase keys to Envato Pty Ltd and use the response from their API to register your validated support data. See the Envato privacy policy here: Envato Privacy Policy.
TICKSY
Ticksy provides the support ticketing platform we use to handle support requests. The data they receive is limited to the data you explicitly provide and consent to being set when you create a support ticket. Ticksy adheres to the EU/US “Privacy Shield” and you can see their privacy policy here: Ticksy Privacy Policy.
7. HOW LONG WE RETAIN YOUR DATA
When you submit a support ticket or a comment, its metadata is retained until (if) you tell us to remove it. We use this data so that we can recognize you and approve your comments automatically instead of holding them for moderation.
If you register on our website, we also store the personal information you provide in your user profile. You can see, edit, or delete your personal information at any time (except changing your username). Website administrators can also see and edit that information.
8. SECURITY MEASURES
We use the SSL/HTTPS protocol throughout our site. This encrypts our user communications with the servers so that personal identifiable information is not captured/hijacked by third parties without authorization.
In case of a data breach, system administrators will immediately take all needed steps to ensure system integrity, will contact affected users and will attempt to reset passwords if needed.
9. YOUR DATA RIGHTS
GENERAL RIGHTS
If you have a registered account on this website or have left comments, you can request an exported file of the personal data we retain, including any additional data you have provided to us.
You can also request that we erase any of the personal data we have stored. This does not include any data we are obliged to keep for administrative, legal, or security purposes. In short, we cannot erase data that is vital to you being an active customer (i.e. basic account information like an email address).
If you wish that all of your data is erased, we will no longer be able to offer any support or other product-related services to you.
GDPR RIGHTS
Your privacy is critically important to us. Going forward with the GDPR we aim to support the GDPR standard. AxiomThemes permits residents of the European Union to use its Service. Therefore, it is the intent of AxiomThemes to comply with the European General Data Protection Regulation. For more details please see here: EU GDPR Information Portal.
10. THIRD PARTY WEBSITES
AxiomThemes may post links to third party websites on this website. These third party websites are not screened for privacy or security compliance by AxiomThemes , and you release us from any liability for the conduct of these third party websites.
All social media sharing links, either displayed as text links or social media icons do not connect you to any of the associated third parties, unless you explicitly click on them.
Please be aware that this Privacy Policy, and any other policies in place, in addition to any amendments, does not create rights enforceable by third parties or require disclosure of any personal information relating to members of the Service or Site. AxiomThemes bears no responsibility for the information collected or used by any advertiser or third party website. Please review the privacy policy and terms of service for each site you visit through third party links.
11. RELEASE OF YOUR DATA FOR LEGAL PURPOSES
At times it may become necessary or desirable to AxiomThemes, for legal purposes, to release your information in response to a request from a government agency or a private litigant. You agree that we may disclose your information to a third party where we believe, in good faith, that it is desirable to do so for the purposes of a civil action, criminal investigation, or other legal matter. In the event that we receive a subpoena affecting your privacy, we may elect to notify you to give you an opportunity to file a motion to quash the subpoena, or we may attempt to quash it ourselves, but we are not obligated to do either. We may also proactively report you, and release your information to, third parties where we believe that it is prudent to do so for legal reasons, such as our belief that you have engaged in fraudulent activities. You release us from any damages that may arise from or relate to the release of your information to a request from law enforcement agencies or private litigants.
Any passing on of personal data for legal purposes will only be done in compliance with laws of the country you reside in.
12. AMENDMENTS
We may amend this Privacy Policy from time to time. When we amend this Privacy Policy, we will update this page accordingly and require you to accept the amendments in order to be permitted to continue using our services.