Office policies requiring appointment rescheduling:

     1. Late arrival:      I understand that if I am 10 minutes late for an appointment, my visit will need to be rescheduled to allow adequate time with the doctor.

     2. Paperwork not submitted prior to appointment:      I understand that my completed paperwork is not submitted prior to my appointment, my visit will need to be rescheduled to allow adequate time with the doctor.

     3. Cancellation policy: 24-hour notice is required.  If you need to cancel your appointment, you will be allowed to reschedule without penalty one time.  If a second cancellation occurs, a deposit of $50 will be required to reschedule.  This is non-refundable but will be applied to your amount due on your first visit.  This is not billable to your insurance.

Financial policies

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    1. Payment:      I understand that all payments for copays, coinsurance, and deductibles are due at the time of my visit. I understand any balance owed after my insurance processes are my financial responsibility.  Self-pay must pay at the time-of-service to receive this discount.

     *** We accept cash, checks, American Express, Visa, Mastercard, Discover, and Paypal.   A $36 fee will be charged for returned checks. ***

    2. Insurance:   I understand that it is my responsibility to know my chiropractic benefits prior to my appointment.  I also agree to supply Fern Creek Chiropractic Center with all up-to-date information regarding my insurance benefits.  I understand that if I do not do this and the insurance benefits cannot be filed in a timely manner, I am financially responsible for the balance.  If you feel your insurance has processed incorrectly, you must contact the company and ask for the correction.

    3. Non-covered services:   I understand that I am responsible for payment of all non-covered or non-medically necessary services.

    4. Collections:  I understand if my balance remains unpaid and is submitted to collections, a 40% collections fee will be added to the outstanding balance and you will be dismissed from our practice.  Once the debt is paid and your account is in good standing, you may apply to be reinstated with our practice.

     5. Medical Records:  I understand I am entitled to 1 free copy of my records.  After the first copy, a fee of $1 per page with a minimum of $15 will be charged.  Your x-rays are permanent records of our office and must remain for 7 years.  You may check them out temporarily if necessary.

Assignment of Insurance Benefits

I hereby instruct and direct my insurance company to pay for the professional or medical expense benefits allowable, and otherwise payable to me under my current insurance policy as payment toward the total charges for the professional services rendered by check made out and mailed to Fern Creek Chiropractic Center, PSC, 6521 Bardstown Road, Louisville, KY 40291

If my current policy prohibits direct payment to the doctor, I hereby also instruct and direct you to make out the check to me and mail it to Fern Creek Chiropractic Center, PSC, 6521 Bardstown Road, Louisville, KY 40291

I authorize the Doctor to deposit checks received on my account when made out to me.

THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above – mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional service charges over and above this insurance payment. A photocopy of this Assignment shall be considered as effective and valid as the original.

I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case.

I authorize the doctor to initiate a complaint to the Insurance Commissioner for any reason on my behalf.

Informed Consent for Chiropractic Care

     DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THESE STATEMENTS

The Use of Protected Health Information & Verification of Receipt of Information

☐I give Fern Creek Chiropractic Center, PSC permission to use and disclose my protected health information and my other information in my file in accordance with the directives listed in the Notice of Privacy Practices for Protected Health Information.

☐I acknowledge that I have received the Chiropractic Clinic’s Notice of Privacy Practices for Protected Health Information and/or know where to find it online.

Open Room Adjusting

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I give Fern Creek Chiropractic Center, PSC permission to treat me in an open room where other patients are also being treated.  I am aware that other persons in the office may overhear some of my protected health information during the course of care.  Should I need to speak with one of the doctors at any time in private, I know I have to alert one of the staff to make arrangements for these conversations.

Consent to Treatment of a Minor/Child (UNDER 18 YEARS OF AGE)

I, ________________ being the parent or legal guardian of __________________ have read and fully understand the above Informed Consent for Chiropractic Care and hereby grant permission for my child to receive Chiropractic care at Fern Creek Chiropractic Center.

I have read and understand the house rules.