PEDIATRIC NEW PATIENT INFORMATION ~ PATIENTINFORMATIONmiddot Childs Name Childs Nickname -~
_ Reason for Visit ------------------------------ -- ~ Sex M I F Date ofBirth Age ___ Childs SS
Childs Home Phone --------shy Child s Home Address Who may we thank for referring you
FAMILY INFORMATION Mother s Name Fathers name
bull Home Phone Home Phone ~ Work Phone Work Phone
~-- Parents Marital Statns Married Single __ Divorced Widowed List Ages ofOther Children in Family
Jl~ Predominant language used at home middot
~-middot PAYMENT INFORMATION ~- Please read and sign om- Financial Agreement Does your health insnrance cover chiropractic Y I N
Ifyou have insurance that may cover chiropractic services please provide yotrr ctrrrent insurance card so that we may middot make a copy Additionally please enter the following information relating to the person who is responsible for the - middot
childs health insurance coverage middot Insureds Name Birth date SS
~ Insurance Company Name Phone No ~
~- Insurance Company Address to send claims ---------------- ------- N bull Employer Group No Insureds ID ~ CONSENTTOTREAT ~
~- Being the parent or legal guardian of this child l hereby authorize this office and its doctors to examine and ~_ administer care to my son I daughter named as the bull examining I treating doctor deems necessary middot shy
I understand and agree the I am personal]y responsible for payment ofall fees charged by this office for such care ~~ ~ Date Witnessedby copy 2001 by Peter Fysh DC AD rights =vecL bull
-------------middot--middot--------------- shy
7PREGNANCY HISTORY t~
__j[Todays Date
__~Childs Name __________ Sex M F DateofBirth _____ Age __
t~ Mothers Name ----------- How many children do you have ___
What was the term ofyour pregnancy ___ weeks
DURING YOUR PREGNANCY DID YOU HAVE ANY OF THE FOLLOWING
u 1 u
u
u u
Falls
Motor V chicle Accidents
Near-miss MVA
High BP
Diabetes
Anemia
Morning sickness
Indigestion
Seizures
Swollen ankles
Thyroid problems
Heart problems
Back pain
Abnormal bleeding
Were you hospitalized
Any other Illnesses
Yes No
DO DO DO DO DO DO DO DO DO DO DO DO DO DO DO DO
17 ~--1_7 0~
u u
u u DURING YOUR PREGNANCY DID YOU USE ANY OF THE FOLLOWING ~~ u
Yes No
Tobacco DO ________________________ _ u uDO ________________________ ___Alcoholu DO uNon-prescribed drugs
Prescription medications D D Medication------- ----- shyReasonu Over -the-counter meds 0 D Medication------- Reason u u ~
u u 0~
1r U 2-r Ucopy 2001 by Peter Fysh DC All rights reserved
uuu~~~~~~~~~~~~~~u
------------------------------------ shy
uu~u~~~~~~u~~~~~uu u BIRTH HISTORY ~~ u u
LABOR AND DELIVERY u How long was the labor from the first regular contractions to the birth ___ _ hours
u How long was the 2nd stage (the pushing phase) of the labor _____ hours
Yes No
Hospital birth D D __________ Home birth DOD 0---------shyMidwife assisted ~r Vaginal Delivery DO _____________ tr
DO _____________Planned C-section
Emergency C-section D D ___________ u DO u
Was Birth Induced (Pitocin)
DO Forceps delivery
DOVacuum extraction uDOAnesthesia administered
DO uFetal distress
DOMeconium staining
DO u Head presentation
DOFace presentation uDOBreech presentation u uBABYS CONDITION IMMEDIATELY AFTER BIRTH
Apgar Scores At 1 minute __ 10 At 5 minutes __ 10 u Baby s Crying Baby Cried Immediately After Birth __
Cried Strongly Weak Cry Did Not Cry for __ minutes
u Babys Color Pink all over Blue face Blue Handsfeet
Babys activity Anns and legs actively moving Floppy babyu Intensive Care Was required Days in Neonatal Intensive Care Unit
u Medication given at birth Vaccines administered
u Birth weight ___ lbs kgs Birth length ins I ems Baby home on day ----shy
u PRE-SCHOOL CHILD HISTORY u1J 3 years to 5 years 1J ~ Todays Date ~
H Childs Name Sex M F Date of Birth _______ H u ~ u ~ Reason for Todays Visit ~
H Yes No HD D Does your child complain of pain or discomfort If yes when did this occur
U Was onset Sudden D or Gradual D Is problem Constant D or Intermittent D U ~ YDes DNo ~ W Has your child ever had this problem before H
Yes No
~ D D Has your child previously been treated for this problem By whom ~ H Yes No Hu D D Has your child previously had chiropractic care Previous chiropractor u
HEALTH HISTORY
~ YDes DNo ~ H Does your child ever complain of back or neck pain --------------- H ~ YDes DNo ~ ~~ Does your child ever complain of pains in the legs or arms ------------ ~~
Yes No
~ D D Does your child ever complain of headaches ~ H Yes No Hu e9a uHas your child had asthma
~ D D Is your child allergic to anything ~ H Yes No Hu ~Des DNo Are there any smokers in the childs home u
0 Has your child had any earaches At what age did the childs first earache occur
)~ ~H How frequently does your child have earaches H
~ In which ear do your childs earaches usually occur Right D Left D Both D ~ H Yes No Hu D D Is your child presently taking any prescribed medication u
Please list any other illness which have been a concern for your child u uu uPlease list any surgeries your child has had
u ~~ uu 0 0 Do you have aoy olhec ooooembull about youc chlds health u ~ PAGE1of2 ~
H copy 2001 byPeterFysh DC All rights reserved H
uuuuuuuuuuuuuuuuuu
UUUUUUUUUUUUuUUUUU u [
J___
uH
~ H ~ H
~ uH
J___
uH
~ ~~ ~
W
U u ~ H
)~
uH
uu U uu u
PRE-SCHOOL CHILD HISTORY 3 years to 5 years
TRAUMA Yes No
D D Has your child had any recent falls or trauma
Describe the trauma and the date it occurred
YDesD~ Has your child ever fallen from a bicycle skateboard scooter rollerblades or similar ___
YDesDNo Has your child ever fallen down stairs or fallen from a significant height
Yes No
D D Has your child ever been in a motor vehicle collision or near-miss Yes Noe~ Has your child ever had a bone fracture or joint dislocation
D D Has your child had any other trauma or injuries Yes No
0 0 Does your child ever bang hl-r baad repeatedly against a wall bed or other object
YDNTRID~ON Do you have any concerns about your childs diet
Yes No
[] D Does your child have any food allergies
YDesDNo Does your child have any persistent or interrnittenUy occuring skin rashes
Yes No
D D Does your child take vitamin supplements Yes No
0 0 Does your child eliminate stools each day
For how many months was your child breast-fed
What does your child usually eat for Breakfast
What does your child usually eat for Lunch
What does your child usually eat for Dinner-------------------- shy
What does your child usually eat for Snacks
How much cows milk does your child drink each day
What is your childs favorite food
What type of fast foods does your child like to eat
PAGE2of2
copy2001 byPeterFyshDC Allrightsreserved
u [
J_
uH
~ H ~ W
u ~ H
~
uH
~ ~~
u ~
W
u ~ H
~
uH
Uu U uu u
uuuuuuuuuuuuuuuuuu
--------------------
WOLF RIVER CHIROPRATIC APPOINTMENT POLICY
Office visits are scheduled accordingly to the severity of your condition and the program of chiropractic care that the doctor feels is best for you Because your condition requires numerous appointments over the next few weeks or months we have designed a multiple appointment program for your convenience This procedure minimizes your time in the office and facilitates incorporating your appointments into your daily routine The frequency of your visitation schedule is of paramount importance to your results so we ask that each patient assume the responsibility of strict adherence to the appointment program as it is designed for optimum results
Our Goal is to provide quality individualized chiropractic care in a timely manner to patients No shows and late cancellations inconvenience the practice and those needing to get in for care These policies enable us to better utilize available appointments for our patients in need of chiropractic care
Regardless of how many appointments are scheduled for you in each week please note that it is the frequency of visits that count not the days on which you receive the service If for any reason you are unable to keep an appointment we require that you telephone immediately (920)240-4441 to reschedule the visit When at all possible it is the patients obligation to make up a missed appointment within 7 days of any cancellation Our staff will try toreshyschedule you the same day or within 24 hours to make-up any missed appointments
Unless canceled in advance our policy is to charge for missed appointments at the rate of a normal office visit This charge will be your responsibility and CANNOT be billed to your insurance company The courtesy of canceling in advance is appreciated by other patients in need of care
Late Cancellations A late cancellation is considered when a patient fails to cancel their scheduled appointment with a 24 hour advance notice
No Show Policy A no-show is someone who misses an appointment without cancelling in an adequate manner A failure to be present at the time of a scheduled appointment will be recorded in the patients chart as a no show This includes arriving 15 minutes after your scheduled appointment
Note that after the 3d late cancellation or no show we reserve the right to discharge the patient from care in our office in addition to billing the patient for each missed office visit
After normal office hours weekends amp holiday visits will include an extra $30 charge in addition to normal service charges
When entering the office on any given visit please go directly to the front desk and sign-in on the form located within your patient file We sincerely attempt to honor all appointments at the scheduled time If you are late you may be asked to wait for the next available appointment If we are unexpectedly running behind we will attempt to call you and advise you on the status of your appointment time If you have any questions regarding our office policy or your appointments please do not hesitate to ask
Signature ___________________
Print Name Date __________________
WOLF RJVER CHIROFRACTIC LLC FINANCIAL POLICY
Thank you for choosing us as your health care provider We are committed to your health Please understand that payment of your bill is expected in exchange for the professional services we offer
The following is a statement of our financial policy which we require you to read and sign prior to treatment
PAYMENT IS DUE AT TIME OF SERVICE We accept cash checks debit transactions VISA MASTERCARD and CARE CREDIT We offer extended payment plans and cash discount plans for those who qualify If payment is not made to our office in a timely manner you will be turned over to a collections agency for payment which will affect your credit rating In the event your account is turned over to collections or a collection agency an additional fee of 30 of the total balance reported to collections will be added to any outstanding patient account balance We reserve the right to charge interest at the rate of 12 as provided by state law
INSURANCE Please give your insurance card to our front desk assistant We will be happy to verify coverage for you but ultimately you are expected to understand your plan coverage We will bill your insurance company as a courtesy to you Always inform us of any insurance changes We accept assignment of most insurance benefits However we do require your portion of the bill to be paid at the time of service THE BALANCE IS YOUR RESPONSIBILITY WHETHER YOUR INSURANCE PAYS OR NOT Your insurance policy is a contract between you and your insurance company If your insurance company has not honored their portion of payment within 60 days the balance will be transferred to you In some cases part and perhaps all of the services provided may not be covered or considered medically necessary by Medicare Medical Assistance and or other insurance plans Our practice is committed to delivering the best care for our patients and we will provide whatever treatment is necessary regardless of any insurance companys arbitrary determinations We will do our best to assist you if any disputes arise with an insurance company
MEDICARE We will submit assigned claims to Medicare on your behalf for covered services If services are approved Medicare will pay 80 of Medicares allowable charges for the service The remaining 20 will be submitted to you or your secondary insurance (if applicable) You will be responsible for any allowed amounts not paid by insurance If services are not approved or are not covered you will be responsible for payment in full Please understand Medicare DOES NOT cover any examinations x-rays extremity adjustments or maintenance care
MEDICALASSISTANCE We will submit claims to Medical Assistance for all covered services You will be responsible for payment of all non-covered services and your co-payment at the time of service per the coverage of your plan
DISCOUNTS We offer a discount for payment made at the time of service (cash discounts) financial arrangement plans and offer discounts to military members in addition to our in-network insurance contracts with carriers
MINOR PATIENTS The parent or guardian accompanying a minor is responsible for full payment of the account
MISSED APPOINTMENTS Please make every effort to maintain your appointments and your schedule of care Our staff wil l try to re-schedule you the same day or within 24 hours to make up any missed appointments Unless canceled in advance our policy is to charge for missed appointments at the rate of a normal office visit This charge will be your responsibility and CANNOT be billed to your insurance company The courtesy of canceling in advance is appreciated by all and shows respect for our time
Thank you for understanding our Financial Policy Please let us know if you have any questions or concerns I have read the Financial Policy outlined by Wolf River Chiropractic LLC and I understand and agree to this policy
Signature_______________ Date ____________
Printed Name ---------------------------shy
ADVANCE PATIENT NOTIFICATION
We provide excellent services to our patients in good faith and expect compensation accordingly It is your duty as a patient to
know and understand your insurance plan which is subject to your plan provisions Health insurance is a contract between you and
your health insurance company or carrier not our office
Should your insurance company determine services provided in our office are not medically necessary deny payment or coverage we reserve the right to transfer any balance owed to you
I understand that the normal fee for the treatment I will be receiving is Initial Examination $50shy$195 Re-examinations $40-$150 X-rays $80-$120 per area Spinal adjustments $45-$90 Nutritional
Note if our office is in-network with your health insurance carrier the rates may fluctuate I understand the expected value of care is estimated at the full prices listed below
1 Examination ($95) X-rays ($280)(Full Spine Sectional with Cervical FlexionExtension Views) 8 Adjustments ($6500each)= $520 8 Therapies (1 per visit)($30 each)=$240 Custom Foot Orthotics ($467) Nutritional Counseling $180 (3 sessions at $60 each) Total estimated cost =$1 78200 Additionally Alcat Testing can be performed at the cost up to $120000 + $5000 mobile lab fee Cold LaserLight Therapy ($20 per session) Other
All nutritional supplementation and supplies MUST be paid for prior to leaving our office There are absolutely NO RETURNS FOR ANY NUTRITIONAL SUPPLEMENTATION this includes UNOPENED
OPENEDUSED SUPPLIES
This is NOT a guarantee you will be billed this amount but is an advance notification of office charges that can accrue during the course of treatment
I understand my health care provider will make recommendations based upon medical necessity for my condition but cannot guarantee insurance reimbursement This is only an estimate and my
treatment plan will be determined by my health care provider based upon my unique needs and response to care
This notification applies from this date forward and is good for all patient cases and conditions
Signature of Patient or Guardian Date
Staff Initials _______ Effective Date
Informed Consent to Chiropractic Treatment
The Nature of Chiropractic Treatment The doctor will use hisher hands j or a mechanical device in order to move your joints You may feel a click or
pop similar to the noise produced when a knuckle is cracked and you may feel movement of the joint Various ancillary procedures such as hot or cold
packs electric muscle stimulation therapeutic ultrasound trigger point therapy or manualmechanical traction may also be used
Possible Risks As with any health care procedures complications are possible following a chiropractic manipulation Complications could conceivably include fracture of bone muscular strain ligamentous sprain dislocations of joints or injury to intervertebral discs nerves or spinal cord A minority of patients may notice stiffness or soreness after the first few days of treatment The ancil lary procedures could produce skin irritation burns or other minor complications There are reported cases of stroke associated with visits to medical doctors and chiropractors Research and scientific evidence does not establish a cause and effect relationship between chiropractic treatment and the occurrence of stroke rather recent studies indicate that patients may be consulting medical doctors and chiropractors when they are in the early stages of a stroke The possibility of such injuries occurring in associat ion with upper cervical adjustment is extremely remote
Probability of Risks Occurring The risks of complications due to chiropractic treatment have been described as rare to extremely rare statistically less often than complications from taking a single aspirin tablet
Other treatment options which could be considered may include the following 1 Over-the-counter analgesics The risks of these medications include irritation to stomach liver
and kidneys and other side effects in a significant number of cases 2 Medical care typically anti-inflammatory drugs tranquilizers and analgesics Risks of these
drugs include a multitude of undesirable side effects and patient dependence in a significant number of cases
3 Hospitalization in conjunct ion with medical care adds risk of exposure to virulent communicable disease in a significant number of cases
4 Surgery in conjunction with medical care adds the risks of adverse reaction to anesthesia as well as an extended convalescent period in a significant number of cases
Risks of Remaining Untreated Delay of treatment allows formation of adhesions scar tissue and other degenerative changes These changes can further reduce skeletal mobility and induce chronic pain cycles It is quite probable that delay of treatment will complicate the condition and make future rehabilitation more difficult
Unusual Risks I have had the following unusual risks of my case explained to me
I have read the above explanation of chiropractic treatment I have had the opportunity to have any questions answered to my satisfaction I have fully evaluated the risks and benefits of undergoing treatment I have freely decided to undergo the recommended treatment and hereby give my full consent to treatment
Printed Name Signature Date
7PREGNANCY HISTORY t~
__j[Todays Date
__~Childs Name __________ Sex M F DateofBirth _____ Age __
t~ Mothers Name ----------- How many children do you have ___
What was the term ofyour pregnancy ___ weeks
DURING YOUR PREGNANCY DID YOU HAVE ANY OF THE FOLLOWING
u 1 u
u
u u
Falls
Motor V chicle Accidents
Near-miss MVA
High BP
Diabetes
Anemia
Morning sickness
Indigestion
Seizures
Swollen ankles
Thyroid problems
Heart problems
Back pain
Abnormal bleeding
Were you hospitalized
Any other Illnesses
Yes No
DO DO DO DO DO DO DO DO DO DO DO DO DO DO DO DO
17 ~--1_7 0~
u u
u u DURING YOUR PREGNANCY DID YOU USE ANY OF THE FOLLOWING ~~ u
Yes No
Tobacco DO ________________________ _ u uDO ________________________ ___Alcoholu DO uNon-prescribed drugs
Prescription medications D D Medication------- ----- shyReasonu Over -the-counter meds 0 D Medication------- Reason u u ~
u u 0~
1r U 2-r Ucopy 2001 by Peter Fysh DC All rights reserved
uuu~~~~~~~~~~~~~~u
------------------------------------ shy
uu~u~~~~~~u~~~~~uu u BIRTH HISTORY ~~ u u
LABOR AND DELIVERY u How long was the labor from the first regular contractions to the birth ___ _ hours
u How long was the 2nd stage (the pushing phase) of the labor _____ hours
Yes No
Hospital birth D D __________ Home birth DOD 0---------shyMidwife assisted ~r Vaginal Delivery DO _____________ tr
DO _____________Planned C-section
Emergency C-section D D ___________ u DO u
Was Birth Induced (Pitocin)
DO Forceps delivery
DOVacuum extraction uDOAnesthesia administered
DO uFetal distress
DOMeconium staining
DO u Head presentation
DOFace presentation uDOBreech presentation u uBABYS CONDITION IMMEDIATELY AFTER BIRTH
Apgar Scores At 1 minute __ 10 At 5 minutes __ 10 u Baby s Crying Baby Cried Immediately After Birth __
Cried Strongly Weak Cry Did Not Cry for __ minutes
u Babys Color Pink all over Blue face Blue Handsfeet
Babys activity Anns and legs actively moving Floppy babyu Intensive Care Was required Days in Neonatal Intensive Care Unit
u Medication given at birth Vaccines administered
u Birth weight ___ lbs kgs Birth length ins I ems Baby home on day ----shy
u PRE-SCHOOL CHILD HISTORY u1J 3 years to 5 years 1J ~ Todays Date ~
H Childs Name Sex M F Date of Birth _______ H u ~ u ~ Reason for Todays Visit ~
H Yes No HD D Does your child complain of pain or discomfort If yes when did this occur
U Was onset Sudden D or Gradual D Is problem Constant D or Intermittent D U ~ YDes DNo ~ W Has your child ever had this problem before H
Yes No
~ D D Has your child previously been treated for this problem By whom ~ H Yes No Hu D D Has your child previously had chiropractic care Previous chiropractor u
HEALTH HISTORY
~ YDes DNo ~ H Does your child ever complain of back or neck pain --------------- H ~ YDes DNo ~ ~~ Does your child ever complain of pains in the legs or arms ------------ ~~
Yes No
~ D D Does your child ever complain of headaches ~ H Yes No Hu e9a uHas your child had asthma
~ D D Is your child allergic to anything ~ H Yes No Hu ~Des DNo Are there any smokers in the childs home u
0 Has your child had any earaches At what age did the childs first earache occur
)~ ~H How frequently does your child have earaches H
~ In which ear do your childs earaches usually occur Right D Left D Both D ~ H Yes No Hu D D Is your child presently taking any prescribed medication u
Please list any other illness which have been a concern for your child u uu uPlease list any surgeries your child has had
u ~~ uu 0 0 Do you have aoy olhec ooooembull about youc chlds health u ~ PAGE1of2 ~
H copy 2001 byPeterFysh DC All rights reserved H
uuuuuuuuuuuuuuuuuu
UUUUUUUUUUUUuUUUUU u [
J___
uH
~ H ~ H
~ uH
J___
uH
~ ~~ ~
W
U u ~ H
)~
uH
uu U uu u
PRE-SCHOOL CHILD HISTORY 3 years to 5 years
TRAUMA Yes No
D D Has your child had any recent falls or trauma
Describe the trauma and the date it occurred
YDesD~ Has your child ever fallen from a bicycle skateboard scooter rollerblades or similar ___
YDesDNo Has your child ever fallen down stairs or fallen from a significant height
Yes No
D D Has your child ever been in a motor vehicle collision or near-miss Yes Noe~ Has your child ever had a bone fracture or joint dislocation
D D Has your child had any other trauma or injuries Yes No
0 0 Does your child ever bang hl-r baad repeatedly against a wall bed or other object
YDNTRID~ON Do you have any concerns about your childs diet
Yes No
[] D Does your child have any food allergies
YDesDNo Does your child have any persistent or interrnittenUy occuring skin rashes
Yes No
D D Does your child take vitamin supplements Yes No
0 0 Does your child eliminate stools each day
For how many months was your child breast-fed
What does your child usually eat for Breakfast
What does your child usually eat for Lunch
What does your child usually eat for Dinner-------------------- shy
What does your child usually eat for Snacks
How much cows milk does your child drink each day
What is your childs favorite food
What type of fast foods does your child like to eat
PAGE2of2
copy2001 byPeterFyshDC Allrightsreserved
u [
J_
uH
~ H ~ W
u ~ H
~
uH
~ ~~
u ~
W
u ~ H
~
uH
Uu U uu u
uuuuuuuuuuuuuuuuuu
--------------------
WOLF RIVER CHIROPRATIC APPOINTMENT POLICY
Office visits are scheduled accordingly to the severity of your condition and the program of chiropractic care that the doctor feels is best for you Because your condition requires numerous appointments over the next few weeks or months we have designed a multiple appointment program for your convenience This procedure minimizes your time in the office and facilitates incorporating your appointments into your daily routine The frequency of your visitation schedule is of paramount importance to your results so we ask that each patient assume the responsibility of strict adherence to the appointment program as it is designed for optimum results
Our Goal is to provide quality individualized chiropractic care in a timely manner to patients No shows and late cancellations inconvenience the practice and those needing to get in for care These policies enable us to better utilize available appointments for our patients in need of chiropractic care
Regardless of how many appointments are scheduled for you in each week please note that it is the frequency of visits that count not the days on which you receive the service If for any reason you are unable to keep an appointment we require that you telephone immediately (920)240-4441 to reschedule the visit When at all possible it is the patients obligation to make up a missed appointment within 7 days of any cancellation Our staff will try toreshyschedule you the same day or within 24 hours to make-up any missed appointments
Unless canceled in advance our policy is to charge for missed appointments at the rate of a normal office visit This charge will be your responsibility and CANNOT be billed to your insurance company The courtesy of canceling in advance is appreciated by other patients in need of care
Late Cancellations A late cancellation is considered when a patient fails to cancel their scheduled appointment with a 24 hour advance notice
No Show Policy A no-show is someone who misses an appointment without cancelling in an adequate manner A failure to be present at the time of a scheduled appointment will be recorded in the patients chart as a no show This includes arriving 15 minutes after your scheduled appointment
Note that after the 3d late cancellation or no show we reserve the right to discharge the patient from care in our office in addition to billing the patient for each missed office visit
After normal office hours weekends amp holiday visits will include an extra $30 charge in addition to normal service charges
When entering the office on any given visit please go directly to the front desk and sign-in on the form located within your patient file We sincerely attempt to honor all appointments at the scheduled time If you are late you may be asked to wait for the next available appointment If we are unexpectedly running behind we will attempt to call you and advise you on the status of your appointment time If you have any questions regarding our office policy or your appointments please do not hesitate to ask
Signature ___________________
Print Name Date __________________
WOLF RJVER CHIROFRACTIC LLC FINANCIAL POLICY
Thank you for choosing us as your health care provider We are committed to your health Please understand that payment of your bill is expected in exchange for the professional services we offer
The following is a statement of our financial policy which we require you to read and sign prior to treatment
PAYMENT IS DUE AT TIME OF SERVICE We accept cash checks debit transactions VISA MASTERCARD and CARE CREDIT We offer extended payment plans and cash discount plans for those who qualify If payment is not made to our office in a timely manner you will be turned over to a collections agency for payment which will affect your credit rating In the event your account is turned over to collections or a collection agency an additional fee of 30 of the total balance reported to collections will be added to any outstanding patient account balance We reserve the right to charge interest at the rate of 12 as provided by state law
INSURANCE Please give your insurance card to our front desk assistant We will be happy to verify coverage for you but ultimately you are expected to understand your plan coverage We will bill your insurance company as a courtesy to you Always inform us of any insurance changes We accept assignment of most insurance benefits However we do require your portion of the bill to be paid at the time of service THE BALANCE IS YOUR RESPONSIBILITY WHETHER YOUR INSURANCE PAYS OR NOT Your insurance policy is a contract between you and your insurance company If your insurance company has not honored their portion of payment within 60 days the balance will be transferred to you In some cases part and perhaps all of the services provided may not be covered or considered medically necessary by Medicare Medical Assistance and or other insurance plans Our practice is committed to delivering the best care for our patients and we will provide whatever treatment is necessary regardless of any insurance companys arbitrary determinations We will do our best to assist you if any disputes arise with an insurance company
MEDICARE We will submit assigned claims to Medicare on your behalf for covered services If services are approved Medicare will pay 80 of Medicares allowable charges for the service The remaining 20 will be submitted to you or your secondary insurance (if applicable) You will be responsible for any allowed amounts not paid by insurance If services are not approved or are not covered you will be responsible for payment in full Please understand Medicare DOES NOT cover any examinations x-rays extremity adjustments or maintenance care
MEDICALASSISTANCE We will submit claims to Medical Assistance for all covered services You will be responsible for payment of all non-covered services and your co-payment at the time of service per the coverage of your plan
DISCOUNTS We offer a discount for payment made at the time of service (cash discounts) financial arrangement plans and offer discounts to military members in addition to our in-network insurance contracts with carriers
MINOR PATIENTS The parent or guardian accompanying a minor is responsible for full payment of the account
MISSED APPOINTMENTS Please make every effort to maintain your appointments and your schedule of care Our staff wil l try to re-schedule you the same day or within 24 hours to make up any missed appointments Unless canceled in advance our policy is to charge for missed appointments at the rate of a normal office visit This charge will be your responsibility and CANNOT be billed to your insurance company The courtesy of canceling in advance is appreciated by all and shows respect for our time
Thank you for understanding our Financial Policy Please let us know if you have any questions or concerns I have read the Financial Policy outlined by Wolf River Chiropractic LLC and I understand and agree to this policy
Signature_______________ Date ____________
Printed Name ---------------------------shy
ADVANCE PATIENT NOTIFICATION
We provide excellent services to our patients in good faith and expect compensation accordingly It is your duty as a patient to
know and understand your insurance plan which is subject to your plan provisions Health insurance is a contract between you and
your health insurance company or carrier not our office
Should your insurance company determine services provided in our office are not medically necessary deny payment or coverage we reserve the right to transfer any balance owed to you
I understand that the normal fee for the treatment I will be receiving is Initial Examination $50shy$195 Re-examinations $40-$150 X-rays $80-$120 per area Spinal adjustments $45-$90 Nutritional
Note if our office is in-network with your health insurance carrier the rates may fluctuate I understand the expected value of care is estimated at the full prices listed below
1 Examination ($95) X-rays ($280)(Full Spine Sectional with Cervical FlexionExtension Views) 8 Adjustments ($6500each)= $520 8 Therapies (1 per visit)($30 each)=$240 Custom Foot Orthotics ($467) Nutritional Counseling $180 (3 sessions at $60 each) Total estimated cost =$1 78200 Additionally Alcat Testing can be performed at the cost up to $120000 + $5000 mobile lab fee Cold LaserLight Therapy ($20 per session) Other
All nutritional supplementation and supplies MUST be paid for prior to leaving our office There are absolutely NO RETURNS FOR ANY NUTRITIONAL SUPPLEMENTATION this includes UNOPENED
OPENEDUSED SUPPLIES
This is NOT a guarantee you will be billed this amount but is an advance notification of office charges that can accrue during the course of treatment
I understand my health care provider will make recommendations based upon medical necessity for my condition but cannot guarantee insurance reimbursement This is only an estimate and my
treatment plan will be determined by my health care provider based upon my unique needs and response to care
This notification applies from this date forward and is good for all patient cases and conditions
Signature of Patient or Guardian Date
Staff Initials _______ Effective Date
Informed Consent to Chiropractic Treatment
The Nature of Chiropractic Treatment The doctor will use hisher hands j or a mechanical device in order to move your joints You may feel a click or
pop similar to the noise produced when a knuckle is cracked and you may feel movement of the joint Various ancillary procedures such as hot or cold
packs electric muscle stimulation therapeutic ultrasound trigger point therapy or manualmechanical traction may also be used
Possible Risks As with any health care procedures complications are possible following a chiropractic manipulation Complications could conceivably include fracture of bone muscular strain ligamentous sprain dislocations of joints or injury to intervertebral discs nerves or spinal cord A minority of patients may notice stiffness or soreness after the first few days of treatment The ancil lary procedures could produce skin irritation burns or other minor complications There are reported cases of stroke associated with visits to medical doctors and chiropractors Research and scientific evidence does not establish a cause and effect relationship between chiropractic treatment and the occurrence of stroke rather recent studies indicate that patients may be consulting medical doctors and chiropractors when they are in the early stages of a stroke The possibility of such injuries occurring in associat ion with upper cervical adjustment is extremely remote
Probability of Risks Occurring The risks of complications due to chiropractic treatment have been described as rare to extremely rare statistically less often than complications from taking a single aspirin tablet
Other treatment options which could be considered may include the following 1 Over-the-counter analgesics The risks of these medications include irritation to stomach liver
and kidneys and other side effects in a significant number of cases 2 Medical care typically anti-inflammatory drugs tranquilizers and analgesics Risks of these
drugs include a multitude of undesirable side effects and patient dependence in a significant number of cases
3 Hospitalization in conjunct ion with medical care adds risk of exposure to virulent communicable disease in a significant number of cases
4 Surgery in conjunction with medical care adds the risks of adverse reaction to anesthesia as well as an extended convalescent period in a significant number of cases
Risks of Remaining Untreated Delay of treatment allows formation of adhesions scar tissue and other degenerative changes These changes can further reduce skeletal mobility and induce chronic pain cycles It is quite probable that delay of treatment will complicate the condition and make future rehabilitation more difficult
Unusual Risks I have had the following unusual risks of my case explained to me
I have read the above explanation of chiropractic treatment I have had the opportunity to have any questions answered to my satisfaction I have fully evaluated the risks and benefits of undergoing treatment I have freely decided to undergo the recommended treatment and hereby give my full consent to treatment
Printed Name Signature Date
uu~u~~~~~~u~~~~~uu u BIRTH HISTORY ~~ u u
LABOR AND DELIVERY u How long was the labor from the first regular contractions to the birth ___ _ hours
u How long was the 2nd stage (the pushing phase) of the labor _____ hours
Yes No
Hospital birth D D __________ Home birth DOD 0---------shyMidwife assisted ~r Vaginal Delivery DO _____________ tr
DO _____________Planned C-section
Emergency C-section D D ___________ u DO u
Was Birth Induced (Pitocin)
DO Forceps delivery
DOVacuum extraction uDOAnesthesia administered
DO uFetal distress
DOMeconium staining
DO u Head presentation
DOFace presentation uDOBreech presentation u uBABYS CONDITION IMMEDIATELY AFTER BIRTH
Apgar Scores At 1 minute __ 10 At 5 minutes __ 10 u Baby s Crying Baby Cried Immediately After Birth __
Cried Strongly Weak Cry Did Not Cry for __ minutes
u Babys Color Pink all over Blue face Blue Handsfeet
Babys activity Anns and legs actively moving Floppy babyu Intensive Care Was required Days in Neonatal Intensive Care Unit
u Medication given at birth Vaccines administered
u Birth weight ___ lbs kgs Birth length ins I ems Baby home on day ----shy
u PRE-SCHOOL CHILD HISTORY u1J 3 years to 5 years 1J ~ Todays Date ~
H Childs Name Sex M F Date of Birth _______ H u ~ u ~ Reason for Todays Visit ~
H Yes No HD D Does your child complain of pain or discomfort If yes when did this occur
U Was onset Sudden D or Gradual D Is problem Constant D or Intermittent D U ~ YDes DNo ~ W Has your child ever had this problem before H
Yes No
~ D D Has your child previously been treated for this problem By whom ~ H Yes No Hu D D Has your child previously had chiropractic care Previous chiropractor u
HEALTH HISTORY
~ YDes DNo ~ H Does your child ever complain of back or neck pain --------------- H ~ YDes DNo ~ ~~ Does your child ever complain of pains in the legs or arms ------------ ~~
Yes No
~ D D Does your child ever complain of headaches ~ H Yes No Hu e9a uHas your child had asthma
~ D D Is your child allergic to anything ~ H Yes No Hu ~Des DNo Are there any smokers in the childs home u
0 Has your child had any earaches At what age did the childs first earache occur
)~ ~H How frequently does your child have earaches H
~ In which ear do your childs earaches usually occur Right D Left D Both D ~ H Yes No Hu D D Is your child presently taking any prescribed medication u
Please list any other illness which have been a concern for your child u uu uPlease list any surgeries your child has had
u ~~ uu 0 0 Do you have aoy olhec ooooembull about youc chlds health u ~ PAGE1of2 ~
H copy 2001 byPeterFysh DC All rights reserved H
uuuuuuuuuuuuuuuuuu
UUUUUUUUUUUUuUUUUU u [
J___
uH
~ H ~ H
~ uH
J___
uH
~ ~~ ~
W
U u ~ H
)~
uH
uu U uu u
PRE-SCHOOL CHILD HISTORY 3 years to 5 years
TRAUMA Yes No
D D Has your child had any recent falls or trauma
Describe the trauma and the date it occurred
YDesD~ Has your child ever fallen from a bicycle skateboard scooter rollerblades or similar ___
YDesDNo Has your child ever fallen down stairs or fallen from a significant height
Yes No
D D Has your child ever been in a motor vehicle collision or near-miss Yes Noe~ Has your child ever had a bone fracture or joint dislocation
D D Has your child had any other trauma or injuries Yes No
0 0 Does your child ever bang hl-r baad repeatedly against a wall bed or other object
YDNTRID~ON Do you have any concerns about your childs diet
Yes No
[] D Does your child have any food allergies
YDesDNo Does your child have any persistent or interrnittenUy occuring skin rashes
Yes No
D D Does your child take vitamin supplements Yes No
0 0 Does your child eliminate stools each day
For how many months was your child breast-fed
What does your child usually eat for Breakfast
What does your child usually eat for Lunch
What does your child usually eat for Dinner-------------------- shy
What does your child usually eat for Snacks
How much cows milk does your child drink each day
What is your childs favorite food
What type of fast foods does your child like to eat
PAGE2of2
copy2001 byPeterFyshDC Allrightsreserved
u [
J_
uH
~ H ~ W
u ~ H
~
uH
~ ~~
u ~
W
u ~ H
~
uH
Uu U uu u
uuuuuuuuuuuuuuuuuu
--------------------
WOLF RIVER CHIROPRATIC APPOINTMENT POLICY
Office visits are scheduled accordingly to the severity of your condition and the program of chiropractic care that the doctor feels is best for you Because your condition requires numerous appointments over the next few weeks or months we have designed a multiple appointment program for your convenience This procedure minimizes your time in the office and facilitates incorporating your appointments into your daily routine The frequency of your visitation schedule is of paramount importance to your results so we ask that each patient assume the responsibility of strict adherence to the appointment program as it is designed for optimum results
Our Goal is to provide quality individualized chiropractic care in a timely manner to patients No shows and late cancellations inconvenience the practice and those needing to get in for care These policies enable us to better utilize available appointments for our patients in need of chiropractic care
Regardless of how many appointments are scheduled for you in each week please note that it is the frequency of visits that count not the days on which you receive the service If for any reason you are unable to keep an appointment we require that you telephone immediately (920)240-4441 to reschedule the visit When at all possible it is the patients obligation to make up a missed appointment within 7 days of any cancellation Our staff will try toreshyschedule you the same day or within 24 hours to make-up any missed appointments
Unless canceled in advance our policy is to charge for missed appointments at the rate of a normal office visit This charge will be your responsibility and CANNOT be billed to your insurance company The courtesy of canceling in advance is appreciated by other patients in need of care
Late Cancellations A late cancellation is considered when a patient fails to cancel their scheduled appointment with a 24 hour advance notice
No Show Policy A no-show is someone who misses an appointment without cancelling in an adequate manner A failure to be present at the time of a scheduled appointment will be recorded in the patients chart as a no show This includes arriving 15 minutes after your scheduled appointment
Note that after the 3d late cancellation or no show we reserve the right to discharge the patient from care in our office in addition to billing the patient for each missed office visit
After normal office hours weekends amp holiday visits will include an extra $30 charge in addition to normal service charges
When entering the office on any given visit please go directly to the front desk and sign-in on the form located within your patient file We sincerely attempt to honor all appointments at the scheduled time If you are late you may be asked to wait for the next available appointment If we are unexpectedly running behind we will attempt to call you and advise you on the status of your appointment time If you have any questions regarding our office policy or your appointments please do not hesitate to ask
Signature ___________________
Print Name Date __________________
WOLF RJVER CHIROFRACTIC LLC FINANCIAL POLICY
Thank you for choosing us as your health care provider We are committed to your health Please understand that payment of your bill is expected in exchange for the professional services we offer
The following is a statement of our financial policy which we require you to read and sign prior to treatment
PAYMENT IS DUE AT TIME OF SERVICE We accept cash checks debit transactions VISA MASTERCARD and CARE CREDIT We offer extended payment plans and cash discount plans for those who qualify If payment is not made to our office in a timely manner you will be turned over to a collections agency for payment which will affect your credit rating In the event your account is turned over to collections or a collection agency an additional fee of 30 of the total balance reported to collections will be added to any outstanding patient account balance We reserve the right to charge interest at the rate of 12 as provided by state law
INSURANCE Please give your insurance card to our front desk assistant We will be happy to verify coverage for you but ultimately you are expected to understand your plan coverage We will bill your insurance company as a courtesy to you Always inform us of any insurance changes We accept assignment of most insurance benefits However we do require your portion of the bill to be paid at the time of service THE BALANCE IS YOUR RESPONSIBILITY WHETHER YOUR INSURANCE PAYS OR NOT Your insurance policy is a contract between you and your insurance company If your insurance company has not honored their portion of payment within 60 days the balance will be transferred to you In some cases part and perhaps all of the services provided may not be covered or considered medically necessary by Medicare Medical Assistance and or other insurance plans Our practice is committed to delivering the best care for our patients and we will provide whatever treatment is necessary regardless of any insurance companys arbitrary determinations We will do our best to assist you if any disputes arise with an insurance company
MEDICARE We will submit assigned claims to Medicare on your behalf for covered services If services are approved Medicare will pay 80 of Medicares allowable charges for the service The remaining 20 will be submitted to you or your secondary insurance (if applicable) You will be responsible for any allowed amounts not paid by insurance If services are not approved or are not covered you will be responsible for payment in full Please understand Medicare DOES NOT cover any examinations x-rays extremity adjustments or maintenance care
MEDICALASSISTANCE We will submit claims to Medical Assistance for all covered services You will be responsible for payment of all non-covered services and your co-payment at the time of service per the coverage of your plan
DISCOUNTS We offer a discount for payment made at the time of service (cash discounts) financial arrangement plans and offer discounts to military members in addition to our in-network insurance contracts with carriers
MINOR PATIENTS The parent or guardian accompanying a minor is responsible for full payment of the account
MISSED APPOINTMENTS Please make every effort to maintain your appointments and your schedule of care Our staff wil l try to re-schedule you the same day or within 24 hours to make up any missed appointments Unless canceled in advance our policy is to charge for missed appointments at the rate of a normal office visit This charge will be your responsibility and CANNOT be billed to your insurance company The courtesy of canceling in advance is appreciated by all and shows respect for our time
Thank you for understanding our Financial Policy Please let us know if you have any questions or concerns I have read the Financial Policy outlined by Wolf River Chiropractic LLC and I understand and agree to this policy
Signature_______________ Date ____________
Printed Name ---------------------------shy
ADVANCE PATIENT NOTIFICATION
We provide excellent services to our patients in good faith and expect compensation accordingly It is your duty as a patient to
know and understand your insurance plan which is subject to your plan provisions Health insurance is a contract between you and
your health insurance company or carrier not our office
Should your insurance company determine services provided in our office are not medically necessary deny payment or coverage we reserve the right to transfer any balance owed to you
I understand that the normal fee for the treatment I will be receiving is Initial Examination $50shy$195 Re-examinations $40-$150 X-rays $80-$120 per area Spinal adjustments $45-$90 Nutritional
Note if our office is in-network with your health insurance carrier the rates may fluctuate I understand the expected value of care is estimated at the full prices listed below
1 Examination ($95) X-rays ($280)(Full Spine Sectional with Cervical FlexionExtension Views) 8 Adjustments ($6500each)= $520 8 Therapies (1 per visit)($30 each)=$240 Custom Foot Orthotics ($467) Nutritional Counseling $180 (3 sessions at $60 each) Total estimated cost =$1 78200 Additionally Alcat Testing can be performed at the cost up to $120000 + $5000 mobile lab fee Cold LaserLight Therapy ($20 per session) Other
All nutritional supplementation and supplies MUST be paid for prior to leaving our office There are absolutely NO RETURNS FOR ANY NUTRITIONAL SUPPLEMENTATION this includes UNOPENED
OPENEDUSED SUPPLIES
This is NOT a guarantee you will be billed this amount but is an advance notification of office charges that can accrue during the course of treatment
I understand my health care provider will make recommendations based upon medical necessity for my condition but cannot guarantee insurance reimbursement This is only an estimate and my
treatment plan will be determined by my health care provider based upon my unique needs and response to care
This notification applies from this date forward and is good for all patient cases and conditions
Signature of Patient or Guardian Date
Staff Initials _______ Effective Date
Informed Consent to Chiropractic Treatment
The Nature of Chiropractic Treatment The doctor will use hisher hands j or a mechanical device in order to move your joints You may feel a click or
pop similar to the noise produced when a knuckle is cracked and you may feel movement of the joint Various ancillary procedures such as hot or cold
packs electric muscle stimulation therapeutic ultrasound trigger point therapy or manualmechanical traction may also be used
Possible Risks As with any health care procedures complications are possible following a chiropractic manipulation Complications could conceivably include fracture of bone muscular strain ligamentous sprain dislocations of joints or injury to intervertebral discs nerves or spinal cord A minority of patients may notice stiffness or soreness after the first few days of treatment The ancil lary procedures could produce skin irritation burns or other minor complications There are reported cases of stroke associated with visits to medical doctors and chiropractors Research and scientific evidence does not establish a cause and effect relationship between chiropractic treatment and the occurrence of stroke rather recent studies indicate that patients may be consulting medical doctors and chiropractors when they are in the early stages of a stroke The possibility of such injuries occurring in associat ion with upper cervical adjustment is extremely remote
Probability of Risks Occurring The risks of complications due to chiropractic treatment have been described as rare to extremely rare statistically less often than complications from taking a single aspirin tablet
Other treatment options which could be considered may include the following 1 Over-the-counter analgesics The risks of these medications include irritation to stomach liver
and kidneys and other side effects in a significant number of cases 2 Medical care typically anti-inflammatory drugs tranquilizers and analgesics Risks of these
drugs include a multitude of undesirable side effects and patient dependence in a significant number of cases
3 Hospitalization in conjunct ion with medical care adds risk of exposure to virulent communicable disease in a significant number of cases
4 Surgery in conjunction with medical care adds the risks of adverse reaction to anesthesia as well as an extended convalescent period in a significant number of cases
Risks of Remaining Untreated Delay of treatment allows formation of adhesions scar tissue and other degenerative changes These changes can further reduce skeletal mobility and induce chronic pain cycles It is quite probable that delay of treatment will complicate the condition and make future rehabilitation more difficult
Unusual Risks I have had the following unusual risks of my case explained to me
I have read the above explanation of chiropractic treatment I have had the opportunity to have any questions answered to my satisfaction I have fully evaluated the risks and benefits of undergoing treatment I have freely decided to undergo the recommended treatment and hereby give my full consent to treatment
Printed Name Signature Date
uuuuu~uuuuuu~uuuuu
u PRE-SCHOOL CHILD HISTORY u1J 3 years to 5 years 1J ~ Todays Date ~
H Childs Name Sex M F Date of Birth _______ H u ~ u ~ Reason for Todays Visit ~
H Yes No HD D Does your child complain of pain or discomfort If yes when did this occur
U Was onset Sudden D or Gradual D Is problem Constant D or Intermittent D U ~ YDes DNo ~ W Has your child ever had this problem before H
Yes No
~ D D Has your child previously been treated for this problem By whom ~ H Yes No Hu D D Has your child previously had chiropractic care Previous chiropractor u
HEALTH HISTORY
~ YDes DNo ~ H Does your child ever complain of back or neck pain --------------- H ~ YDes DNo ~ ~~ Does your child ever complain of pains in the legs or arms ------------ ~~
Yes No
~ D D Does your child ever complain of headaches ~ H Yes No Hu e9a uHas your child had asthma
~ D D Is your child allergic to anything ~ H Yes No Hu ~Des DNo Are there any smokers in the childs home u
0 Has your child had any earaches At what age did the childs first earache occur
)~ ~H How frequently does your child have earaches H
~ In which ear do your childs earaches usually occur Right D Left D Both D ~ H Yes No Hu D D Is your child presently taking any prescribed medication u
Please list any other illness which have been a concern for your child u uu uPlease list any surgeries your child has had
u ~~ uu 0 0 Do you have aoy olhec ooooembull about youc chlds health u ~ PAGE1of2 ~
H copy 2001 byPeterFysh DC All rights reserved H
uuuuuuuuuuuuuuuuuu
UUUUUUUUUUUUuUUUUU u [
J___
uH
~ H ~ H
~ uH
J___
uH
~ ~~ ~
W
U u ~ H
)~
uH
uu U uu u
PRE-SCHOOL CHILD HISTORY 3 years to 5 years
TRAUMA Yes No
D D Has your child had any recent falls or trauma
Describe the trauma and the date it occurred
YDesD~ Has your child ever fallen from a bicycle skateboard scooter rollerblades or similar ___
YDesDNo Has your child ever fallen down stairs or fallen from a significant height
Yes No
D D Has your child ever been in a motor vehicle collision or near-miss Yes Noe~ Has your child ever had a bone fracture or joint dislocation
D D Has your child had any other trauma or injuries Yes No
0 0 Does your child ever bang hl-r baad repeatedly against a wall bed or other object
YDNTRID~ON Do you have any concerns about your childs diet
Yes No
[] D Does your child have any food allergies
YDesDNo Does your child have any persistent or interrnittenUy occuring skin rashes
Yes No
D D Does your child take vitamin supplements Yes No
0 0 Does your child eliminate stools each day
For how many months was your child breast-fed
What does your child usually eat for Breakfast
What does your child usually eat for Lunch
What does your child usually eat for Dinner-------------------- shy
What does your child usually eat for Snacks
How much cows milk does your child drink each day
What is your childs favorite food
What type of fast foods does your child like to eat
PAGE2of2
copy2001 byPeterFyshDC Allrightsreserved
u [
J_
uH
~ H ~ W
u ~ H
~
uH
~ ~~
u ~
W
u ~ H
~
uH
Uu U uu u
uuuuuuuuuuuuuuuuuu
--------------------
WOLF RIVER CHIROPRATIC APPOINTMENT POLICY
Office visits are scheduled accordingly to the severity of your condition and the program of chiropractic care that the doctor feels is best for you Because your condition requires numerous appointments over the next few weeks or months we have designed a multiple appointment program for your convenience This procedure minimizes your time in the office and facilitates incorporating your appointments into your daily routine The frequency of your visitation schedule is of paramount importance to your results so we ask that each patient assume the responsibility of strict adherence to the appointment program as it is designed for optimum results
Our Goal is to provide quality individualized chiropractic care in a timely manner to patients No shows and late cancellations inconvenience the practice and those needing to get in for care These policies enable us to better utilize available appointments for our patients in need of chiropractic care
Regardless of how many appointments are scheduled for you in each week please note that it is the frequency of visits that count not the days on which you receive the service If for any reason you are unable to keep an appointment we require that you telephone immediately (920)240-4441 to reschedule the visit When at all possible it is the patients obligation to make up a missed appointment within 7 days of any cancellation Our staff will try toreshyschedule you the same day or within 24 hours to make-up any missed appointments
Unless canceled in advance our policy is to charge for missed appointments at the rate of a normal office visit This charge will be your responsibility and CANNOT be billed to your insurance company The courtesy of canceling in advance is appreciated by other patients in need of care
Late Cancellations A late cancellation is considered when a patient fails to cancel their scheduled appointment with a 24 hour advance notice
No Show Policy A no-show is someone who misses an appointment without cancelling in an adequate manner A failure to be present at the time of a scheduled appointment will be recorded in the patients chart as a no show This includes arriving 15 minutes after your scheduled appointment
Note that after the 3d late cancellation or no show we reserve the right to discharge the patient from care in our office in addition to billing the patient for each missed office visit
After normal office hours weekends amp holiday visits will include an extra $30 charge in addition to normal service charges
When entering the office on any given visit please go directly to the front desk and sign-in on the form located within your patient file We sincerely attempt to honor all appointments at the scheduled time If you are late you may be asked to wait for the next available appointment If we are unexpectedly running behind we will attempt to call you and advise you on the status of your appointment time If you have any questions regarding our office policy or your appointments please do not hesitate to ask
Signature ___________________
Print Name Date __________________
WOLF RJVER CHIROFRACTIC LLC FINANCIAL POLICY
Thank you for choosing us as your health care provider We are committed to your health Please understand that payment of your bill is expected in exchange for the professional services we offer
The following is a statement of our financial policy which we require you to read and sign prior to treatment
PAYMENT IS DUE AT TIME OF SERVICE We accept cash checks debit transactions VISA MASTERCARD and CARE CREDIT We offer extended payment plans and cash discount plans for those who qualify If payment is not made to our office in a timely manner you will be turned over to a collections agency for payment which will affect your credit rating In the event your account is turned over to collections or a collection agency an additional fee of 30 of the total balance reported to collections will be added to any outstanding patient account balance We reserve the right to charge interest at the rate of 12 as provided by state law
INSURANCE Please give your insurance card to our front desk assistant We will be happy to verify coverage for you but ultimately you are expected to understand your plan coverage We will bill your insurance company as a courtesy to you Always inform us of any insurance changes We accept assignment of most insurance benefits However we do require your portion of the bill to be paid at the time of service THE BALANCE IS YOUR RESPONSIBILITY WHETHER YOUR INSURANCE PAYS OR NOT Your insurance policy is a contract between you and your insurance company If your insurance company has not honored their portion of payment within 60 days the balance will be transferred to you In some cases part and perhaps all of the services provided may not be covered or considered medically necessary by Medicare Medical Assistance and or other insurance plans Our practice is committed to delivering the best care for our patients and we will provide whatever treatment is necessary regardless of any insurance companys arbitrary determinations We will do our best to assist you if any disputes arise with an insurance company
MEDICARE We will submit assigned claims to Medicare on your behalf for covered services If services are approved Medicare will pay 80 of Medicares allowable charges for the service The remaining 20 will be submitted to you or your secondary insurance (if applicable) You will be responsible for any allowed amounts not paid by insurance If services are not approved or are not covered you will be responsible for payment in full Please understand Medicare DOES NOT cover any examinations x-rays extremity adjustments or maintenance care
MEDICALASSISTANCE We will submit claims to Medical Assistance for all covered services You will be responsible for payment of all non-covered services and your co-payment at the time of service per the coverage of your plan
DISCOUNTS We offer a discount for payment made at the time of service (cash discounts) financial arrangement plans and offer discounts to military members in addition to our in-network insurance contracts with carriers
MINOR PATIENTS The parent or guardian accompanying a minor is responsible for full payment of the account
MISSED APPOINTMENTS Please make every effort to maintain your appointments and your schedule of care Our staff wil l try to re-schedule you the same day or within 24 hours to make up any missed appointments Unless canceled in advance our policy is to charge for missed appointments at the rate of a normal office visit This charge will be your responsibility and CANNOT be billed to your insurance company The courtesy of canceling in advance is appreciated by all and shows respect for our time
Thank you for understanding our Financial Policy Please let us know if you have any questions or concerns I have read the Financial Policy outlined by Wolf River Chiropractic LLC and I understand and agree to this policy
Signature_______________ Date ____________
Printed Name ---------------------------shy
ADVANCE PATIENT NOTIFICATION
We provide excellent services to our patients in good faith and expect compensation accordingly It is your duty as a patient to
know and understand your insurance plan which is subject to your plan provisions Health insurance is a contract between you and
your health insurance company or carrier not our office
Should your insurance company determine services provided in our office are not medically necessary deny payment or coverage we reserve the right to transfer any balance owed to you
I understand that the normal fee for the treatment I will be receiving is Initial Examination $50shy$195 Re-examinations $40-$150 X-rays $80-$120 per area Spinal adjustments $45-$90 Nutritional
Note if our office is in-network with your health insurance carrier the rates may fluctuate I understand the expected value of care is estimated at the full prices listed below
1 Examination ($95) X-rays ($280)(Full Spine Sectional with Cervical FlexionExtension Views) 8 Adjustments ($6500each)= $520 8 Therapies (1 per visit)($30 each)=$240 Custom Foot Orthotics ($467) Nutritional Counseling $180 (3 sessions at $60 each) Total estimated cost =$1 78200 Additionally Alcat Testing can be performed at the cost up to $120000 + $5000 mobile lab fee Cold LaserLight Therapy ($20 per session) Other
All nutritional supplementation and supplies MUST be paid for prior to leaving our office There are absolutely NO RETURNS FOR ANY NUTRITIONAL SUPPLEMENTATION this includes UNOPENED
OPENEDUSED SUPPLIES
This is NOT a guarantee you will be billed this amount but is an advance notification of office charges that can accrue during the course of treatment
I understand my health care provider will make recommendations based upon medical necessity for my condition but cannot guarantee insurance reimbursement This is only an estimate and my
treatment plan will be determined by my health care provider based upon my unique needs and response to care
This notification applies from this date forward and is good for all patient cases and conditions
Signature of Patient or Guardian Date
Staff Initials _______ Effective Date
Informed Consent to Chiropractic Treatment
The Nature of Chiropractic Treatment The doctor will use hisher hands j or a mechanical device in order to move your joints You may feel a click or
pop similar to the noise produced when a knuckle is cracked and you may feel movement of the joint Various ancillary procedures such as hot or cold
packs electric muscle stimulation therapeutic ultrasound trigger point therapy or manualmechanical traction may also be used
Possible Risks As with any health care procedures complications are possible following a chiropractic manipulation Complications could conceivably include fracture of bone muscular strain ligamentous sprain dislocations of joints or injury to intervertebral discs nerves or spinal cord A minority of patients may notice stiffness or soreness after the first few days of treatment The ancil lary procedures could produce skin irritation burns or other minor complications There are reported cases of stroke associated with visits to medical doctors and chiropractors Research and scientific evidence does not establish a cause and effect relationship between chiropractic treatment and the occurrence of stroke rather recent studies indicate that patients may be consulting medical doctors and chiropractors when they are in the early stages of a stroke The possibility of such injuries occurring in associat ion with upper cervical adjustment is extremely remote
Probability of Risks Occurring The risks of complications due to chiropractic treatment have been described as rare to extremely rare statistically less often than complications from taking a single aspirin tablet
Other treatment options which could be considered may include the following 1 Over-the-counter analgesics The risks of these medications include irritation to stomach liver
and kidneys and other side effects in a significant number of cases 2 Medical care typically anti-inflammatory drugs tranquilizers and analgesics Risks of these
drugs include a multitude of undesirable side effects and patient dependence in a significant number of cases
3 Hospitalization in conjunct ion with medical care adds risk of exposure to virulent communicable disease in a significant number of cases
4 Surgery in conjunction with medical care adds the risks of adverse reaction to anesthesia as well as an extended convalescent period in a significant number of cases
Risks of Remaining Untreated Delay of treatment allows formation of adhesions scar tissue and other degenerative changes These changes can further reduce skeletal mobility and induce chronic pain cycles It is quite probable that delay of treatment will complicate the condition and make future rehabilitation more difficult
Unusual Risks I have had the following unusual risks of my case explained to me
I have read the above explanation of chiropractic treatment I have had the opportunity to have any questions answered to my satisfaction I have fully evaluated the risks and benefits of undergoing treatment I have freely decided to undergo the recommended treatment and hereby give my full consent to treatment
Printed Name Signature Date
UUUUUUUUUUUUuUUUUU u [
J___
uH
~ H ~ H
~ uH
J___
uH
~ ~~ ~
W
U u ~ H
)~
uH
uu U uu u
PRE-SCHOOL CHILD HISTORY 3 years to 5 years
TRAUMA Yes No
D D Has your child had any recent falls or trauma
Describe the trauma and the date it occurred
YDesD~ Has your child ever fallen from a bicycle skateboard scooter rollerblades or similar ___
YDesDNo Has your child ever fallen down stairs or fallen from a significant height
Yes No
D D Has your child ever been in a motor vehicle collision or near-miss Yes Noe~ Has your child ever had a bone fracture or joint dislocation
D D Has your child had any other trauma or injuries Yes No
0 0 Does your child ever bang hl-r baad repeatedly against a wall bed or other object
YDNTRID~ON Do you have any concerns about your childs diet
Yes No
[] D Does your child have any food allergies
YDesDNo Does your child have any persistent or interrnittenUy occuring skin rashes
Yes No
D D Does your child take vitamin supplements Yes No
0 0 Does your child eliminate stools each day
For how many months was your child breast-fed
What does your child usually eat for Breakfast
What does your child usually eat for Lunch
What does your child usually eat for Dinner-------------------- shy
What does your child usually eat for Snacks
How much cows milk does your child drink each day
What is your childs favorite food
What type of fast foods does your child like to eat
PAGE2of2
copy2001 byPeterFyshDC Allrightsreserved
u [
J_
uH
~ H ~ W
u ~ H
~
uH
~ ~~
u ~
W
u ~ H
~
uH
Uu U uu u
uuuuuuuuuuuuuuuuuu
--------------------
WOLF RIVER CHIROPRATIC APPOINTMENT POLICY
Office visits are scheduled accordingly to the severity of your condition and the program of chiropractic care that the doctor feels is best for you Because your condition requires numerous appointments over the next few weeks or months we have designed a multiple appointment program for your convenience This procedure minimizes your time in the office and facilitates incorporating your appointments into your daily routine The frequency of your visitation schedule is of paramount importance to your results so we ask that each patient assume the responsibility of strict adherence to the appointment program as it is designed for optimum results
Our Goal is to provide quality individualized chiropractic care in a timely manner to patients No shows and late cancellations inconvenience the practice and those needing to get in for care These policies enable us to better utilize available appointments for our patients in need of chiropractic care
Regardless of how many appointments are scheduled for you in each week please note that it is the frequency of visits that count not the days on which you receive the service If for any reason you are unable to keep an appointment we require that you telephone immediately (920)240-4441 to reschedule the visit When at all possible it is the patients obligation to make up a missed appointment within 7 days of any cancellation Our staff will try toreshyschedule you the same day or within 24 hours to make-up any missed appointments
Unless canceled in advance our policy is to charge for missed appointments at the rate of a normal office visit This charge will be your responsibility and CANNOT be billed to your insurance company The courtesy of canceling in advance is appreciated by other patients in need of care
Late Cancellations A late cancellation is considered when a patient fails to cancel their scheduled appointment with a 24 hour advance notice
No Show Policy A no-show is someone who misses an appointment without cancelling in an adequate manner A failure to be present at the time of a scheduled appointment will be recorded in the patients chart as a no show This includes arriving 15 minutes after your scheduled appointment
Note that after the 3d late cancellation or no show we reserve the right to discharge the patient from care in our office in addition to billing the patient for each missed office visit
After normal office hours weekends amp holiday visits will include an extra $30 charge in addition to normal service charges
When entering the office on any given visit please go directly to the front desk and sign-in on the form located within your patient file We sincerely attempt to honor all appointments at the scheduled time If you are late you may be asked to wait for the next available appointment If we are unexpectedly running behind we will attempt to call you and advise you on the status of your appointment time If you have any questions regarding our office policy or your appointments please do not hesitate to ask
Signature ___________________
Print Name Date __________________
WOLF RJVER CHIROFRACTIC LLC FINANCIAL POLICY
Thank you for choosing us as your health care provider We are committed to your health Please understand that payment of your bill is expected in exchange for the professional services we offer
The following is a statement of our financial policy which we require you to read and sign prior to treatment
PAYMENT IS DUE AT TIME OF SERVICE We accept cash checks debit transactions VISA MASTERCARD and CARE CREDIT We offer extended payment plans and cash discount plans for those who qualify If payment is not made to our office in a timely manner you will be turned over to a collections agency for payment which will affect your credit rating In the event your account is turned over to collections or a collection agency an additional fee of 30 of the total balance reported to collections will be added to any outstanding patient account balance We reserve the right to charge interest at the rate of 12 as provided by state law
INSURANCE Please give your insurance card to our front desk assistant We will be happy to verify coverage for you but ultimately you are expected to understand your plan coverage We will bill your insurance company as a courtesy to you Always inform us of any insurance changes We accept assignment of most insurance benefits However we do require your portion of the bill to be paid at the time of service THE BALANCE IS YOUR RESPONSIBILITY WHETHER YOUR INSURANCE PAYS OR NOT Your insurance policy is a contract between you and your insurance company If your insurance company has not honored their portion of payment within 60 days the balance will be transferred to you In some cases part and perhaps all of the services provided may not be covered or considered medically necessary by Medicare Medical Assistance and or other insurance plans Our practice is committed to delivering the best care for our patients and we will provide whatever treatment is necessary regardless of any insurance companys arbitrary determinations We will do our best to assist you if any disputes arise with an insurance company
MEDICARE We will submit assigned claims to Medicare on your behalf for covered services If services are approved Medicare will pay 80 of Medicares allowable charges for the service The remaining 20 will be submitted to you or your secondary insurance (if applicable) You will be responsible for any allowed amounts not paid by insurance If services are not approved or are not covered you will be responsible for payment in full Please understand Medicare DOES NOT cover any examinations x-rays extremity adjustments or maintenance care
MEDICALASSISTANCE We will submit claims to Medical Assistance for all covered services You will be responsible for payment of all non-covered services and your co-payment at the time of service per the coverage of your plan
DISCOUNTS We offer a discount for payment made at the time of service (cash discounts) financial arrangement plans and offer discounts to military members in addition to our in-network insurance contracts with carriers
MINOR PATIENTS The parent or guardian accompanying a minor is responsible for full payment of the account
MISSED APPOINTMENTS Please make every effort to maintain your appointments and your schedule of care Our staff wil l try to re-schedule you the same day or within 24 hours to make up any missed appointments Unless canceled in advance our policy is to charge for missed appointments at the rate of a normal office visit This charge will be your responsibility and CANNOT be billed to your insurance company The courtesy of canceling in advance is appreciated by all and shows respect for our time
Thank you for understanding our Financial Policy Please let us know if you have any questions or concerns I have read the Financial Policy outlined by Wolf River Chiropractic LLC and I understand and agree to this policy
Signature_______________ Date ____________
Printed Name ---------------------------shy
ADVANCE PATIENT NOTIFICATION
We provide excellent services to our patients in good faith and expect compensation accordingly It is your duty as a patient to
know and understand your insurance plan which is subject to your plan provisions Health insurance is a contract between you and
your health insurance company or carrier not our office
Should your insurance company determine services provided in our office are not medically necessary deny payment or coverage we reserve the right to transfer any balance owed to you
I understand that the normal fee for the treatment I will be receiving is Initial Examination $50shy$195 Re-examinations $40-$150 X-rays $80-$120 per area Spinal adjustments $45-$90 Nutritional
Note if our office is in-network with your health insurance carrier the rates may fluctuate I understand the expected value of care is estimated at the full prices listed below
1 Examination ($95) X-rays ($280)(Full Spine Sectional with Cervical FlexionExtension Views) 8 Adjustments ($6500each)= $520 8 Therapies (1 per visit)($30 each)=$240 Custom Foot Orthotics ($467) Nutritional Counseling $180 (3 sessions at $60 each) Total estimated cost =$1 78200 Additionally Alcat Testing can be performed at the cost up to $120000 + $5000 mobile lab fee Cold LaserLight Therapy ($20 per session) Other
All nutritional supplementation and supplies MUST be paid for prior to leaving our office There are absolutely NO RETURNS FOR ANY NUTRITIONAL SUPPLEMENTATION this includes UNOPENED
OPENEDUSED SUPPLIES
This is NOT a guarantee you will be billed this amount but is an advance notification of office charges that can accrue during the course of treatment
I understand my health care provider will make recommendations based upon medical necessity for my condition but cannot guarantee insurance reimbursement This is only an estimate and my
treatment plan will be determined by my health care provider based upon my unique needs and response to care
This notification applies from this date forward and is good for all patient cases and conditions
Signature of Patient or Guardian Date
Staff Initials _______ Effective Date
Informed Consent to Chiropractic Treatment
The Nature of Chiropractic Treatment The doctor will use hisher hands j or a mechanical device in order to move your joints You may feel a click or
pop similar to the noise produced when a knuckle is cracked and you may feel movement of the joint Various ancillary procedures such as hot or cold
packs electric muscle stimulation therapeutic ultrasound trigger point therapy or manualmechanical traction may also be used
Possible Risks As with any health care procedures complications are possible following a chiropractic manipulation Complications could conceivably include fracture of bone muscular strain ligamentous sprain dislocations of joints or injury to intervertebral discs nerves or spinal cord A minority of patients may notice stiffness or soreness after the first few days of treatment The ancil lary procedures could produce skin irritation burns or other minor complications There are reported cases of stroke associated with visits to medical doctors and chiropractors Research and scientific evidence does not establish a cause and effect relationship between chiropractic treatment and the occurrence of stroke rather recent studies indicate that patients may be consulting medical doctors and chiropractors when they are in the early stages of a stroke The possibility of such injuries occurring in associat ion with upper cervical adjustment is extremely remote
Probability of Risks Occurring The risks of complications due to chiropractic treatment have been described as rare to extremely rare statistically less often than complications from taking a single aspirin tablet
Other treatment options which could be considered may include the following 1 Over-the-counter analgesics The risks of these medications include irritation to stomach liver
and kidneys and other side effects in a significant number of cases 2 Medical care typically anti-inflammatory drugs tranquilizers and analgesics Risks of these
drugs include a multitude of undesirable side effects and patient dependence in a significant number of cases
3 Hospitalization in conjunct ion with medical care adds risk of exposure to virulent communicable disease in a significant number of cases
4 Surgery in conjunction with medical care adds the risks of adverse reaction to anesthesia as well as an extended convalescent period in a significant number of cases
Risks of Remaining Untreated Delay of treatment allows formation of adhesions scar tissue and other degenerative changes These changes can further reduce skeletal mobility and induce chronic pain cycles It is quite probable that delay of treatment will complicate the condition and make future rehabilitation more difficult
Unusual Risks I have had the following unusual risks of my case explained to me
I have read the above explanation of chiropractic treatment I have had the opportunity to have any questions answered to my satisfaction I have fully evaluated the risks and benefits of undergoing treatment I have freely decided to undergo the recommended treatment and hereby give my full consent to treatment
Printed Name Signature Date
--------------------
WOLF RIVER CHIROPRATIC APPOINTMENT POLICY
Office visits are scheduled accordingly to the severity of your condition and the program of chiropractic care that the doctor feels is best for you Because your condition requires numerous appointments over the next few weeks or months we have designed a multiple appointment program for your convenience This procedure minimizes your time in the office and facilitates incorporating your appointments into your daily routine The frequency of your visitation schedule is of paramount importance to your results so we ask that each patient assume the responsibility of strict adherence to the appointment program as it is designed for optimum results
Our Goal is to provide quality individualized chiropractic care in a timely manner to patients No shows and late cancellations inconvenience the practice and those needing to get in for care These policies enable us to better utilize available appointments for our patients in need of chiropractic care
Regardless of how many appointments are scheduled for you in each week please note that it is the frequency of visits that count not the days on which you receive the service If for any reason you are unable to keep an appointment we require that you telephone immediately (920)240-4441 to reschedule the visit When at all possible it is the patients obligation to make up a missed appointment within 7 days of any cancellation Our staff will try toreshyschedule you the same day or within 24 hours to make-up any missed appointments
Unless canceled in advance our policy is to charge for missed appointments at the rate of a normal office visit This charge will be your responsibility and CANNOT be billed to your insurance company The courtesy of canceling in advance is appreciated by other patients in need of care
Late Cancellations A late cancellation is considered when a patient fails to cancel their scheduled appointment with a 24 hour advance notice
No Show Policy A no-show is someone who misses an appointment without cancelling in an adequate manner A failure to be present at the time of a scheduled appointment will be recorded in the patients chart as a no show This includes arriving 15 minutes after your scheduled appointment
Note that after the 3d late cancellation or no show we reserve the right to discharge the patient from care in our office in addition to billing the patient for each missed office visit
After normal office hours weekends amp holiday visits will include an extra $30 charge in addition to normal service charges
When entering the office on any given visit please go directly to the front desk and sign-in on the form located within your patient file We sincerely attempt to honor all appointments at the scheduled time If you are late you may be asked to wait for the next available appointment If we are unexpectedly running behind we will attempt to call you and advise you on the status of your appointment time If you have any questions regarding our office policy or your appointments please do not hesitate to ask
Signature ___________________
Print Name Date __________________
WOLF RJVER CHIROFRACTIC LLC FINANCIAL POLICY
Thank you for choosing us as your health care provider We are committed to your health Please understand that payment of your bill is expected in exchange for the professional services we offer
The following is a statement of our financial policy which we require you to read and sign prior to treatment
PAYMENT IS DUE AT TIME OF SERVICE We accept cash checks debit transactions VISA MASTERCARD and CARE CREDIT We offer extended payment plans and cash discount plans for those who qualify If payment is not made to our office in a timely manner you will be turned over to a collections agency for payment which will affect your credit rating In the event your account is turned over to collections or a collection agency an additional fee of 30 of the total balance reported to collections will be added to any outstanding patient account balance We reserve the right to charge interest at the rate of 12 as provided by state law
INSURANCE Please give your insurance card to our front desk assistant We will be happy to verify coverage for you but ultimately you are expected to understand your plan coverage We will bill your insurance company as a courtesy to you Always inform us of any insurance changes We accept assignment of most insurance benefits However we do require your portion of the bill to be paid at the time of service THE BALANCE IS YOUR RESPONSIBILITY WHETHER YOUR INSURANCE PAYS OR NOT Your insurance policy is a contract between you and your insurance company If your insurance company has not honored their portion of payment within 60 days the balance will be transferred to you In some cases part and perhaps all of the services provided may not be covered or considered medically necessary by Medicare Medical Assistance and or other insurance plans Our practice is committed to delivering the best care for our patients and we will provide whatever treatment is necessary regardless of any insurance companys arbitrary determinations We will do our best to assist you if any disputes arise with an insurance company
MEDICARE We will submit assigned claims to Medicare on your behalf for covered services If services are approved Medicare will pay 80 of Medicares allowable charges for the service The remaining 20 will be submitted to you or your secondary insurance (if applicable) You will be responsible for any allowed amounts not paid by insurance If services are not approved or are not covered you will be responsible for payment in full Please understand Medicare DOES NOT cover any examinations x-rays extremity adjustments or maintenance care
MEDICALASSISTANCE We will submit claims to Medical Assistance for all covered services You will be responsible for payment of all non-covered services and your co-payment at the time of service per the coverage of your plan
DISCOUNTS We offer a discount for payment made at the time of service (cash discounts) financial arrangement plans and offer discounts to military members in addition to our in-network insurance contracts with carriers
MINOR PATIENTS The parent or guardian accompanying a minor is responsible for full payment of the account
MISSED APPOINTMENTS Please make every effort to maintain your appointments and your schedule of care Our staff wil l try to re-schedule you the same day or within 24 hours to make up any missed appointments Unless canceled in advance our policy is to charge for missed appointments at the rate of a normal office visit This charge will be your responsibility and CANNOT be billed to your insurance company The courtesy of canceling in advance is appreciated by all and shows respect for our time
Thank you for understanding our Financial Policy Please let us know if you have any questions or concerns I have read the Financial Policy outlined by Wolf River Chiropractic LLC and I understand and agree to this policy
Signature_______________ Date ____________
Printed Name ---------------------------shy
ADVANCE PATIENT NOTIFICATION
We provide excellent services to our patients in good faith and expect compensation accordingly It is your duty as a patient to
know and understand your insurance plan which is subject to your plan provisions Health insurance is a contract between you and
your health insurance company or carrier not our office
Should your insurance company determine services provided in our office are not medically necessary deny payment or coverage we reserve the right to transfer any balance owed to you
I understand that the normal fee for the treatment I will be receiving is Initial Examination $50shy$195 Re-examinations $40-$150 X-rays $80-$120 per area Spinal adjustments $45-$90 Nutritional
Note if our office is in-network with your health insurance carrier the rates may fluctuate I understand the expected value of care is estimated at the full prices listed below
1 Examination ($95) X-rays ($280)(Full Spine Sectional with Cervical FlexionExtension Views) 8 Adjustments ($6500each)= $520 8 Therapies (1 per visit)($30 each)=$240 Custom Foot Orthotics ($467) Nutritional Counseling $180 (3 sessions at $60 each) Total estimated cost =$1 78200 Additionally Alcat Testing can be performed at the cost up to $120000 + $5000 mobile lab fee Cold LaserLight Therapy ($20 per session) Other
All nutritional supplementation and supplies MUST be paid for prior to leaving our office There are absolutely NO RETURNS FOR ANY NUTRITIONAL SUPPLEMENTATION this includes UNOPENED
OPENEDUSED SUPPLIES
This is NOT a guarantee you will be billed this amount but is an advance notification of office charges that can accrue during the course of treatment
I understand my health care provider will make recommendations based upon medical necessity for my condition but cannot guarantee insurance reimbursement This is only an estimate and my
treatment plan will be determined by my health care provider based upon my unique needs and response to care
This notification applies from this date forward and is good for all patient cases and conditions
Signature of Patient or Guardian Date
Staff Initials _______ Effective Date
Informed Consent to Chiropractic Treatment
The Nature of Chiropractic Treatment The doctor will use hisher hands j or a mechanical device in order to move your joints You may feel a click or
pop similar to the noise produced when a knuckle is cracked and you may feel movement of the joint Various ancillary procedures such as hot or cold
packs electric muscle stimulation therapeutic ultrasound trigger point therapy or manualmechanical traction may also be used
Possible Risks As with any health care procedures complications are possible following a chiropractic manipulation Complications could conceivably include fracture of bone muscular strain ligamentous sprain dislocations of joints or injury to intervertebral discs nerves or spinal cord A minority of patients may notice stiffness or soreness after the first few days of treatment The ancil lary procedures could produce skin irritation burns or other minor complications There are reported cases of stroke associated with visits to medical doctors and chiropractors Research and scientific evidence does not establish a cause and effect relationship between chiropractic treatment and the occurrence of stroke rather recent studies indicate that patients may be consulting medical doctors and chiropractors when they are in the early stages of a stroke The possibility of such injuries occurring in associat ion with upper cervical adjustment is extremely remote
Probability of Risks Occurring The risks of complications due to chiropractic treatment have been described as rare to extremely rare statistically less often than complications from taking a single aspirin tablet
Other treatment options which could be considered may include the following 1 Over-the-counter analgesics The risks of these medications include irritation to stomach liver
and kidneys and other side effects in a significant number of cases 2 Medical care typically anti-inflammatory drugs tranquilizers and analgesics Risks of these
drugs include a multitude of undesirable side effects and patient dependence in a significant number of cases
3 Hospitalization in conjunct ion with medical care adds risk of exposure to virulent communicable disease in a significant number of cases
4 Surgery in conjunction with medical care adds the risks of adverse reaction to anesthesia as well as an extended convalescent period in a significant number of cases
Risks of Remaining Untreated Delay of treatment allows formation of adhesions scar tissue and other degenerative changes These changes can further reduce skeletal mobility and induce chronic pain cycles It is quite probable that delay of treatment will complicate the condition and make future rehabilitation more difficult
Unusual Risks I have had the following unusual risks of my case explained to me
I have read the above explanation of chiropractic treatment I have had the opportunity to have any questions answered to my satisfaction I have fully evaluated the risks and benefits of undergoing treatment I have freely decided to undergo the recommended treatment and hereby give my full consent to treatment
Printed Name Signature Date
WOLF RJVER CHIROFRACTIC LLC FINANCIAL POLICY
Thank you for choosing us as your health care provider We are committed to your health Please understand that payment of your bill is expected in exchange for the professional services we offer
The following is a statement of our financial policy which we require you to read and sign prior to treatment
PAYMENT IS DUE AT TIME OF SERVICE We accept cash checks debit transactions VISA MASTERCARD and CARE CREDIT We offer extended payment plans and cash discount plans for those who qualify If payment is not made to our office in a timely manner you will be turned over to a collections agency for payment which will affect your credit rating In the event your account is turned over to collections or a collection agency an additional fee of 30 of the total balance reported to collections will be added to any outstanding patient account balance We reserve the right to charge interest at the rate of 12 as provided by state law
INSURANCE Please give your insurance card to our front desk assistant We will be happy to verify coverage for you but ultimately you are expected to understand your plan coverage We will bill your insurance company as a courtesy to you Always inform us of any insurance changes We accept assignment of most insurance benefits However we do require your portion of the bill to be paid at the time of service THE BALANCE IS YOUR RESPONSIBILITY WHETHER YOUR INSURANCE PAYS OR NOT Your insurance policy is a contract between you and your insurance company If your insurance company has not honored their portion of payment within 60 days the balance will be transferred to you In some cases part and perhaps all of the services provided may not be covered or considered medically necessary by Medicare Medical Assistance and or other insurance plans Our practice is committed to delivering the best care for our patients and we will provide whatever treatment is necessary regardless of any insurance companys arbitrary determinations We will do our best to assist you if any disputes arise with an insurance company
MEDICARE We will submit assigned claims to Medicare on your behalf for covered services If services are approved Medicare will pay 80 of Medicares allowable charges for the service The remaining 20 will be submitted to you or your secondary insurance (if applicable) You will be responsible for any allowed amounts not paid by insurance If services are not approved or are not covered you will be responsible for payment in full Please understand Medicare DOES NOT cover any examinations x-rays extremity adjustments or maintenance care
MEDICALASSISTANCE We will submit claims to Medical Assistance for all covered services You will be responsible for payment of all non-covered services and your co-payment at the time of service per the coverage of your plan
DISCOUNTS We offer a discount for payment made at the time of service (cash discounts) financial arrangement plans and offer discounts to military members in addition to our in-network insurance contracts with carriers
MINOR PATIENTS The parent or guardian accompanying a minor is responsible for full payment of the account
MISSED APPOINTMENTS Please make every effort to maintain your appointments and your schedule of care Our staff wil l try to re-schedule you the same day or within 24 hours to make up any missed appointments Unless canceled in advance our policy is to charge for missed appointments at the rate of a normal office visit This charge will be your responsibility and CANNOT be billed to your insurance company The courtesy of canceling in advance is appreciated by all and shows respect for our time
Thank you for understanding our Financial Policy Please let us know if you have any questions or concerns I have read the Financial Policy outlined by Wolf River Chiropractic LLC and I understand and agree to this policy
Signature_______________ Date ____________
Printed Name ---------------------------shy
ADVANCE PATIENT NOTIFICATION
We provide excellent services to our patients in good faith and expect compensation accordingly It is your duty as a patient to
know and understand your insurance plan which is subject to your plan provisions Health insurance is a contract between you and
your health insurance company or carrier not our office
Should your insurance company determine services provided in our office are not medically necessary deny payment or coverage we reserve the right to transfer any balance owed to you
I understand that the normal fee for the treatment I will be receiving is Initial Examination $50shy$195 Re-examinations $40-$150 X-rays $80-$120 per area Spinal adjustments $45-$90 Nutritional
Note if our office is in-network with your health insurance carrier the rates may fluctuate I understand the expected value of care is estimated at the full prices listed below
1 Examination ($95) X-rays ($280)(Full Spine Sectional with Cervical FlexionExtension Views) 8 Adjustments ($6500each)= $520 8 Therapies (1 per visit)($30 each)=$240 Custom Foot Orthotics ($467) Nutritional Counseling $180 (3 sessions at $60 each) Total estimated cost =$1 78200 Additionally Alcat Testing can be performed at the cost up to $120000 + $5000 mobile lab fee Cold LaserLight Therapy ($20 per session) Other
All nutritional supplementation and supplies MUST be paid for prior to leaving our office There are absolutely NO RETURNS FOR ANY NUTRITIONAL SUPPLEMENTATION this includes UNOPENED
OPENEDUSED SUPPLIES
This is NOT a guarantee you will be billed this amount but is an advance notification of office charges that can accrue during the course of treatment
I understand my health care provider will make recommendations based upon medical necessity for my condition but cannot guarantee insurance reimbursement This is only an estimate and my
treatment plan will be determined by my health care provider based upon my unique needs and response to care
This notification applies from this date forward and is good for all patient cases and conditions
Signature of Patient or Guardian Date
Staff Initials _______ Effective Date
Informed Consent to Chiropractic Treatment
The Nature of Chiropractic Treatment The doctor will use hisher hands j or a mechanical device in order to move your joints You may feel a click or
pop similar to the noise produced when a knuckle is cracked and you may feel movement of the joint Various ancillary procedures such as hot or cold
packs electric muscle stimulation therapeutic ultrasound trigger point therapy or manualmechanical traction may also be used
Possible Risks As with any health care procedures complications are possible following a chiropractic manipulation Complications could conceivably include fracture of bone muscular strain ligamentous sprain dislocations of joints or injury to intervertebral discs nerves or spinal cord A minority of patients may notice stiffness or soreness after the first few days of treatment The ancil lary procedures could produce skin irritation burns or other minor complications There are reported cases of stroke associated with visits to medical doctors and chiropractors Research and scientific evidence does not establish a cause and effect relationship between chiropractic treatment and the occurrence of stroke rather recent studies indicate that patients may be consulting medical doctors and chiropractors when they are in the early stages of a stroke The possibility of such injuries occurring in associat ion with upper cervical adjustment is extremely remote
Probability of Risks Occurring The risks of complications due to chiropractic treatment have been described as rare to extremely rare statistically less often than complications from taking a single aspirin tablet
Other treatment options which could be considered may include the following 1 Over-the-counter analgesics The risks of these medications include irritation to stomach liver
and kidneys and other side effects in a significant number of cases 2 Medical care typically anti-inflammatory drugs tranquilizers and analgesics Risks of these
drugs include a multitude of undesirable side effects and patient dependence in a significant number of cases
3 Hospitalization in conjunct ion with medical care adds risk of exposure to virulent communicable disease in a significant number of cases
4 Surgery in conjunction with medical care adds the risks of adverse reaction to anesthesia as well as an extended convalescent period in a significant number of cases
Risks of Remaining Untreated Delay of treatment allows formation of adhesions scar tissue and other degenerative changes These changes can further reduce skeletal mobility and induce chronic pain cycles It is quite probable that delay of treatment will complicate the condition and make future rehabilitation more difficult
Unusual Risks I have had the following unusual risks of my case explained to me
I have read the above explanation of chiropractic treatment I have had the opportunity to have any questions answered to my satisfaction I have fully evaluated the risks and benefits of undergoing treatment I have freely decided to undergo the recommended treatment and hereby give my full consent to treatment
Printed Name Signature Date
ADVANCE PATIENT NOTIFICATION
We provide excellent services to our patients in good faith and expect compensation accordingly It is your duty as a patient to
know and understand your insurance plan which is subject to your plan provisions Health insurance is a contract between you and
your health insurance company or carrier not our office
Should your insurance company determine services provided in our office are not medically necessary deny payment or coverage we reserve the right to transfer any balance owed to you
I understand that the normal fee for the treatment I will be receiving is Initial Examination $50shy$195 Re-examinations $40-$150 X-rays $80-$120 per area Spinal adjustments $45-$90 Nutritional
Note if our office is in-network with your health insurance carrier the rates may fluctuate I understand the expected value of care is estimated at the full prices listed below
1 Examination ($95) X-rays ($280)(Full Spine Sectional with Cervical FlexionExtension Views) 8 Adjustments ($6500each)= $520 8 Therapies (1 per visit)($30 each)=$240 Custom Foot Orthotics ($467) Nutritional Counseling $180 (3 sessions at $60 each) Total estimated cost =$1 78200 Additionally Alcat Testing can be performed at the cost up to $120000 + $5000 mobile lab fee Cold LaserLight Therapy ($20 per session) Other
All nutritional supplementation and supplies MUST be paid for prior to leaving our office There are absolutely NO RETURNS FOR ANY NUTRITIONAL SUPPLEMENTATION this includes UNOPENED
OPENEDUSED SUPPLIES
This is NOT a guarantee you will be billed this amount but is an advance notification of office charges that can accrue during the course of treatment
I understand my health care provider will make recommendations based upon medical necessity for my condition but cannot guarantee insurance reimbursement This is only an estimate and my
treatment plan will be determined by my health care provider based upon my unique needs and response to care
This notification applies from this date forward and is good for all patient cases and conditions
Signature of Patient or Guardian Date
Staff Initials _______ Effective Date
Informed Consent to Chiropractic Treatment
The Nature of Chiropractic Treatment The doctor will use hisher hands j or a mechanical device in order to move your joints You may feel a click or
pop similar to the noise produced when a knuckle is cracked and you may feel movement of the joint Various ancillary procedures such as hot or cold
packs electric muscle stimulation therapeutic ultrasound trigger point therapy or manualmechanical traction may also be used
Possible Risks As with any health care procedures complications are possible following a chiropractic manipulation Complications could conceivably include fracture of bone muscular strain ligamentous sprain dislocations of joints or injury to intervertebral discs nerves or spinal cord A minority of patients may notice stiffness or soreness after the first few days of treatment The ancil lary procedures could produce skin irritation burns or other minor complications There are reported cases of stroke associated with visits to medical doctors and chiropractors Research and scientific evidence does not establish a cause and effect relationship between chiropractic treatment and the occurrence of stroke rather recent studies indicate that patients may be consulting medical doctors and chiropractors when they are in the early stages of a stroke The possibility of such injuries occurring in associat ion with upper cervical adjustment is extremely remote
Probability of Risks Occurring The risks of complications due to chiropractic treatment have been described as rare to extremely rare statistically less often than complications from taking a single aspirin tablet
Other treatment options which could be considered may include the following 1 Over-the-counter analgesics The risks of these medications include irritation to stomach liver
and kidneys and other side effects in a significant number of cases 2 Medical care typically anti-inflammatory drugs tranquilizers and analgesics Risks of these
drugs include a multitude of undesirable side effects and patient dependence in a significant number of cases
3 Hospitalization in conjunct ion with medical care adds risk of exposure to virulent communicable disease in a significant number of cases
4 Surgery in conjunction with medical care adds the risks of adverse reaction to anesthesia as well as an extended convalescent period in a significant number of cases
Risks of Remaining Untreated Delay of treatment allows formation of adhesions scar tissue and other degenerative changes These changes can further reduce skeletal mobility and induce chronic pain cycles It is quite probable that delay of treatment will complicate the condition and make future rehabilitation more difficult
Unusual Risks I have had the following unusual risks of my case explained to me
I have read the above explanation of chiropractic treatment I have had the opportunity to have any questions answered to my satisfaction I have fully evaluated the risks and benefits of undergoing treatment I have freely decided to undergo the recommended treatment and hereby give my full consent to treatment
Printed Name Signature Date
Informed Consent to Chiropractic Treatment
The Nature of Chiropractic Treatment The doctor will use hisher hands j or a mechanical device in order to move your joints You may feel a click or
pop similar to the noise produced when a knuckle is cracked and you may feel movement of the joint Various ancillary procedures such as hot or cold
packs electric muscle stimulation therapeutic ultrasound trigger point therapy or manualmechanical traction may also be used
Possible Risks As with any health care procedures complications are possible following a chiropractic manipulation Complications could conceivably include fracture of bone muscular strain ligamentous sprain dislocations of joints or injury to intervertebral discs nerves or spinal cord A minority of patients may notice stiffness or soreness after the first few days of treatment The ancil lary procedures could produce skin irritation burns or other minor complications There are reported cases of stroke associated with visits to medical doctors and chiropractors Research and scientific evidence does not establish a cause and effect relationship between chiropractic treatment and the occurrence of stroke rather recent studies indicate that patients may be consulting medical doctors and chiropractors when they are in the early stages of a stroke The possibility of such injuries occurring in associat ion with upper cervical adjustment is extremely remote
Probability of Risks Occurring The risks of complications due to chiropractic treatment have been described as rare to extremely rare statistically less often than complications from taking a single aspirin tablet
Other treatment options which could be considered may include the following 1 Over-the-counter analgesics The risks of these medications include irritation to stomach liver
and kidneys and other side effects in a significant number of cases 2 Medical care typically anti-inflammatory drugs tranquilizers and analgesics Risks of these
drugs include a multitude of undesirable side effects and patient dependence in a significant number of cases
3 Hospitalization in conjunct ion with medical care adds risk of exposure to virulent communicable disease in a significant number of cases
4 Surgery in conjunction with medical care adds the risks of adverse reaction to anesthesia as well as an extended convalescent period in a significant number of cases
Risks of Remaining Untreated Delay of treatment allows formation of adhesions scar tissue and other degenerative changes These changes can further reduce skeletal mobility and induce chronic pain cycles It is quite probable that delay of treatment will complicate the condition and make future rehabilitation more difficult
Unusual Risks I have had the following unusual risks of my case explained to me
I have read the above explanation of chiropractic treatment I have had the opportunity to have any questions answered to my satisfaction I have fully evaluated the risks and benefits of undergoing treatment I have freely decided to undergo the recommended treatment and hereby give my full consent to treatment
