Soreness: l am aware that, like exercise, it is common to experience muscle soreness in the first few treatments.
Fractures/Joint injury: I further understand that an Isolated cases underlying physical deformities or pathologies like weak bones from osteoporosis may render the patient susceptible to Injury. When osteoporosis, degenerative disc, or other abnormality is detected, this office will proceed with extra caution.
Stroke: Although strokes happen with some frequency In our world, stroke from chiropractic adjustments are rare. I am aware that nerve or brain damage including stroke to reported to occur once in one million to once in ten million treatments.
Physical Therapy Burns: Some of the therapies used in this office generate heat and may rarely cause a burn. Despite precautions, If a burn is obtained, there will be a temporary Increase of pain and possible blistering. This should be reported to the doctor. Tests have been performed on me to minimize the risk of complications from treatment, and I freely assume these risks.
I, being the parent or legal guardian of have read and fully understand the above Informed Consent and hereby grant permission for my child to receive chiropractic care and/or physical therapy. I have read or have had read to me the above explanation of chiropractic treatment. Any questions I had regarding these procedures have been answered to my satisfaction PRIOR TO MY SIGNING THIS CONSENT FORM. I have made my decision voluntarily and freely.
To attest to my consent to these procedures, i hereby affix my signature to this authorization for treatment.
350 Forsgate Dr Monroe NJ 08831
AllCure Spine and Sports Medicine is a private professional entity and is not contracted with any insurance plans other than Medicare. Even though we do not participate in your insurance plan's provider network, we pledge to help you understand and manage the financial aspects associated with providing you the very best care and attention you deserve.
Most insurance plans allow patients to select their own treating physician even if the physician they prefer is not in their insurance plan's network. To help you understand your responsibilities, we will inquire as to your plan's out-of-network benefits, and explain what, and if any financial obligations you will have for our services.
Our independence is a hallmark trait of our practice. As an out-of-network provider, the course of treatment we provide will not be limited to what an insurance plan representative will approve, but will instead be solely upon the state-ofthe- art care that your board certified physician recommends.
All charges will be submitted to your insurance carrier on behalf as an out-of-network provider. You may be responsible for your deductible and co-insurance on allowed payments up to your out-of-pocket maximum according to your out-ofnetwork insurance policy. Most insurance plans allow reasonable and customary payment for our services in which case you will not receive any bills. In few cases however, a particular plan may not provide reasonable and customary payment in which case you may be responsible for some of the difference between what is billed and what your insurance plan allows for payment.
In addition, the Horizon Blue Cross Blue shield insurance company may send payment for our services directly to you. You agree to relinquish all payments that you receive from your insurance company for our services to Spine and Sports Medicine of Monroe. Failure to do so will result in legal action.
By signing below, you attest that you completely understand and agree with our financial policy as described above for the services provided by AllCure Spine and Sports Medicine and its professionals.
You have the right to request a restriction or limitation the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a procedure that you had. We ask that you submit these requests in writing. Except under Specific circumstances, we are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment or is required by law. We must agree to restrict the disclosure of protected health information to a health plan for purposes of carrying out payment or health care operations (as defined by HEPPA) if the information pertains solely to a health care item or service for which we have been paid by you out-of-pocket, and in full.
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. We will agree to the request to the extent that it is reasonable for us to do so. For example, you can ask that we use an alternative address for billing purposes. We ask that you submit your request in writing.
You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy. To exercise any of your rights, please obtain the required forms from the Privacy Officer and submit your request in writing.
If you believe your privacy rights have been violated, you may file a complaint with us by calling (732) 521-9222 and asking for the Privacy Officer or by contacting the Secretary of the Federal Department of Health and Human Services. All complaints must be also submitted in writing. You will not be penalized for filing a complaint
I acknowledge having received a copy of the practice's Notice of Privacy Policies.
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