Policy Statements and Acceptance Form

As an integral part of our goal to provide thorough, quality care to our patients, a simplified procedure for payment of professional services and insurance billing has been adapted.

1. Payments may be made by either cash, check, Visa or Mastercard.
2. Should the insurance company require any further information, my signature below is sufficient authorization for this office to release any required information.

Note: Payment in full is expected at the time of service. However, if you are either unable to pay in full at the time of service or if you have insurance that covers chiropractic care the following will be in effect.

1. You (the patient) are expected to meet your deductible and keep your account current by paying the estimated unpaid percentage of fees not covered by your insurance carrier each visit (i.e. if your insurance company pays 80% of the

   costs, then your payments are 20%of the cost of each treatment.

2. You are responsible for both checking that your insurance company is paying in a timely matter, and that any outstanding balance is paid to Heartstone Family Chiropractic. If your insurance company is not keeping current, it is your responsibility to contact them for payment.
3. Some insurance companies will send payment directly to the patient even though our office has “taken assignment” ;you are responsible for signing the check over to our office immediately upon receipt of any money to be paid on your account with us.
4. Either a service charge or a flat rate fee will be added to the outstanding balance on all accounts that are 30 days past due. You are responsible for any and all collection costs that are incurred as a result of nonpayment of your account. A minimum collection fee of $35 will be added to all accounts past 90 days overdue.

All health insurance plans represent a contact between yourself and your insurance company. These contracts are not between the physician and the insurance company. It is therefore your responsibility to see that the insurance carrier makes prompt payments on your account and to handle any dispute or question that may arise. Once again, any cost of treatment that the insurance company does not reimburse is the responsibility of the patient.

• I understand that Heartstone Family Chiropractic will use and disclose health information about me.
• I understand that my health information may include information both created and received by HFC, may be in the form of written or electronic records or spoken words, and may include information about my health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, and similar types of health-related information.
• I understand and agree that HFC may use and disclose my health information in order to: Make decisions about and plan for my care and treatment; refer to, consult with, coordinate among and manage along with other health care providers for my care and treatment; determine my eligibility for health plan or insurance coverage, and submit bills, claims and other related information to insurance companies or others who may be responsible to pay for some or all of my health care; and perform various office, administrative and business functions that support my physician’s efforts to provide me with, arrange and be reimbursed for quality, cost-effective health care.
• I have the right to receive and review a written description of how HFC will handle health information about me. This written description is known as a Notice of Privacy Practices and describes the uses and disclosures of health information made and the information practices followed by the employees, staff and other office personnel of This Practice, and my rights regarding my health information.
• I understand that the Notice of Privacy Practices may be revised from time to time, and that I am entitled to receive a copy of any revised Notice of Privacy Practices.
• I understand that I have the right to ask that some or all of my health information not be used or disclosed in the manner described in the Notice of Privacy Practices, and I understand that This Practice is not required by law to agree to such requests.
• I fully understand Heartstone Family Chiropractic’s Financial and Privacy Policies.

Heartstone Family Chiropractic offers a natural approach when addressing your health concerns. We do so without the use of drugs or surgery. If you feel you need drugs, surgery, or medical intervention, we encourage you to seek that type of care. If, at any time, we feel that medical intervention is necessary, we will refer you to a medical facility.

We do not attempt to diagnose, treat, or cure any diseases. Our goal is to assist your body’s natural abilities to heal itself. This may be done through chiropractic care, trigger point therapy, Cranial Sacral Therapy or lifestyle changes. We do everything possible to detect the underlying causes of your body’s state of health. It is only through eliminating these underlying causes that optimal health can be achieved.

Regarding chiropractic care, certain risks must be disclosed. Complications include, but are not limited to fractures, disc injuries, dislocations, and muscle or ligament strains. There have been reported cases of injury to

the vertebral artery following osseous spinal manipulation. Vertebral artery injuries have been known to cause a stroke, sometimes with serious neurological impairment, and may, on rare occasion, result in paralysis or death. The possibility of such injuries resulting from cervical spine manipulation is extremely remote.

THIS NOTICE DESCRIBES HOW CHIROPRACTIC AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

In the course of your care as a patient at this office we may use or disclose personal and health related information about you in the following ways:

• Your protected 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 or treatment
• Your health care records as well as your billing records may be disclosed to another party, such as an insurance carrier, an HMO ,a PPO, or your employer, if they are or may responsible for the payment of services provided to you.
• Your name, address, phone number, and your health care records may be used to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information that may be of interest to you.

If you are not home to receive an appointment reminder or other related information, a message may be left on your answering machine or with a person in your household. You have a right to confidential communications and to request restrictions relative to such contacts. You also have the right to be contacted by alternative means or at alternative locations.

You have a right to request restrictions on our use of your protected health information for treatment, payment and operations purposes. Such requests are not automatic and require the agreement of this office.

We are permitted and may be required to use or disclose your health information without your authorization in these following circumstances:

• lf we provide health care services to you in an emergency.
• lf we are required by law to provide care to you and we are unable to obtain your consent after attempting to do so.
• If there are substantial barriers to communicating with you, but in our professional judgment we believe that you intend for us to provide care.
• lf we are ordered by the courts or another appropriate agency

You have a right to receive an accounting of any such disclosures made by this office.

Any use or disclosure of your protected health information, other than as outlined above, will only be made upon your written authorization. If you provide an authorization for release of information you have the right to revoke that authorization at a later date.

Information that we use or disclose based on this privacy notice may be subject to re-disclosure by the person to whom we provide the information and may no longer be protected by the federal privacy rules.

We normally provide information about your health 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 If you would like to receive this information at an address other than your home or, if you would like the information in a specific form please advise us in writing as to your preferences.

We are required by state and federal law to maintain the privacy of your patient file and the health protected health information therein. We are also required to provide you with this notice of our privacy practices with respect to your health information. We are further required by law to abide by the terms of this notice while it is in effect.

We reserve the right to alter or amend the terms of this privacy notice. If changes are made to our. privacy notice we will notify you in writing as soon as possible following the changes. Any change in our privacy notice will apply for all of your health information in our files.

if you have a complaint regarding our privacy notice, our privacy practices or any aspect of our privacy activities you should direct your complaint to:

Kevin Michael Phillips, DC, PC

If you would like further information about our privacy policies and practices please contact:

Kevin Michael Phillips, D.C.

You also have the right to lodge a complaint with the Secretary of the Department of Health and Human Services. If you choose to lodge a complaint with this office or with the Secretary your care will continue and you will not be disadvantaged by this office or our staff in any manner whatsoever.

This notice is effective as of June. 1, 2010. This notice, and any alterations or amendments made hereto will expire seven years after the date upon which the record was created.