To the best of my knowledge, the medical information I have provided is complete and correct. I understand it is my responsibility to inform my doctor if I, or my minor child, have any changes in health.

It is very important that our patients have a clear understanding of our expectations regarding their billing and payments. Please read and sign the following financial policy prior to your treatment.

The following prices are estimates and can change without notice. Price ranges start with “Time of Service” rates, and represent prices when paid at the time of the appointment. Your insurance (if applicable) may or may not cover a portion or even all charges depending on your policy.

Professional Fee Statement

Examinations $55 -210
Adjustments $45 - 80
Massage Therapy (per ½ hour) $40 - 52
X-Rays (per region) $70 - 136
Modalities $15 - 25
Exercise/Rehab Procedures $38 - 54

Insurance Policy Coverage

An insurance policy is an agreement between you and your insurance company. Insurance coverage varies greatly and we cannot be certain that your policy will cover the services we provided in our office. While our office can call and verify your insurance over the phone, it is not a guarantee of payment and most insurance companies do not cover 100% of services rendered. The chiropractor may utilize any of the above procedures, separately or combined, at any time during the course of treatment, which may incur additional charges. It is to be understood and agreed that all services rendered to you and your family are your personal responsibility and you are personally responsible for payment of any non- covered services, deductibles, co-pays and co-insurance.

I understand that I am financially responsible for any applicable deductible, co-insurance, or co-pays associated with my policy. Should services be denied, the usual & customary fee schedule listed above should apply. I understand that having insurance does not ensure that my carrier will pay for my chiropractic care. I acknowledge that my plan may have certain restrictions with regard to yearly visit limits, capitated amounts of coverage, etc. I understand that my carrier and I have a contractual agreement and that my provider may or may not be in network with any given insurance plan.

Personal Injury (Auto Accident or Workers Comp)

I understand that I am financially responsible for securing any necessary medical payment plan policy in the event that my care is due to a motor vehicle accident, or any other third party responsibility. I intend to pay 100% of usual and customary fees, and I understand that any monies obtained in settlement will go toward any outstanding balances for care provided at this office.

Medicare

I agree to pay for any necessary co-pays, and/or deductibles associated with my care. I understand that these insurance plans may deny payment for chiropractic services based on their opinion of ‘medical necessity’. I agree to pay any outstanding balances that may result should my policy or supplemental carrier elect to not provide payment for services. Further, I understand that these plans only cover the manipulation, and any other exams/X-rays/therapies/modalities that I receive will be my financial responsibility.

Assignment of Benefits:

Authorization to Pay Benefits to Physician/Office (Statement): I hereby assign payment directly to Live Well Chiropractic for any and all procedures and treatments provided, if any, otherwise payable to me for services provided, but not to exceed the indebtedness to Live Well Chiropractic for those services. I understand that I am financially responsible for charges not covered by my insurance.

Massage Cancellation/No-Show Policy

Cancellations without charge are accepted any time before the close of business on the business day preceding your appointment. This allows the opportunity for someone else to schedule an appointment. If an appointment is not cancelled within this time, a charge of the full appointment price will be applied. A charge of the full appointment price will be applied to scheduled appointments that are either forgotten or unable to be met. This amount must be paid prior to the next scheduled appointment.

My signature below signifies my agreement and understanding with Live Well Chiropactic’s Payment Policy Agreement.

Informed Consent for Care

All health care treatments carry the possibility of complications. Dr. Nathan Edmonds has informed me of the possible risks of chiropractic manipulation and related treatment, and I understand these risks. I have discussed treatment options and their associated risks and benefits with the doctor and all of my questions have been answered. The doctor has recommended chiropractic manipulation and related treatment. I understand the risks and choose to follow his recommendations. Further, I request and give my consent for chiropractic manipulation, massage therapy and related treatment. I intend for this consent to cover all treatments now and in the future by the doctor or any other provider he appoints to administer treatment. I do not expect the doctor to be able to explain all risks and complications. I choose to rely on the doctor to exercise judgment that is in my best interest during treatment.

Notice of Privacy Practices and Disclosure of Protected Health Information

In the course of your care as a patient at our office we may use or disclose personal and health related information about you in the following ways: 1) Your personal health information, including your clinical records, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assessment of treatment. 2) Your health records as well as your billing records may be disclosed to another party, such as insurance carrier (HMO, PPO, etc.) or your employer (if they are responsible for payment). 3) Your name, address, phone number, and your health records may be used to contact you regarding appointment reminder, a message may be left on your answering machine. You also have the right to refuse to provide authorization for this office to contact you regarding these matters. If you do not provide us with this authorization, it will not affect the care provided to you. Under federal law, we are also permitted to use or disclose your health information without your consent or authorization in the following circumstances:

* If we are providing health care services to you based on the orders of another health care provider.

* If we provide health care services to you in an emergency.

* If we are required by law to provide care to you and we are unable to obtain your consent after attempting to.

* If there are substantial barriers to communicating with you, but in our professional judgment we believe that you intend for us to provide care.

We normally provide information about your health care to you in person at the time you receive chiropractic care from us. We may also mail information to you regarding your health care or about the status of your account. By signing below, I acknowledge that I have read the above information and give full disclosure of my information.

Consent of Professional Services and Release of Information

I hereby authorize and release the doctor and whomever he/she may designate as his/her assistants to administer treatment, physical examination, x-ray studies, laboratory procedure, chiropractic care, massage therapy or any clinic services that he/she deems necessary in my case; and further authorize him/her to disclose all or any part of my (patient’s) records to any person or corporation which is or may be liable under a contract to the clinic or the patient or to a family member or employer of the patient for all or part of the clinic’s charge, including, and not limited to, hospital or medical services, companies, insurance companies, workers compensation carriers, welfare funds or the patients’ employer.

My signature below signifies my agreement and understanding with Live Well Chiropactic’s Privacy Policy and Informed Disclosure.