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Information about the person receiving care...

Arbitration Agreement:

Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitrate as provided by state and federal law, and not by a lawsuit or resort to court process except as state and federal law provides for judicial review of arbitrate proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

Article 2: All Claims Must be Arbitrated: It is also understood that any dispute that does not relate to medical malpractice, including disputes as to whether or not a dispute is subject to arbitration, will also be determined by submission to binding arbitration. It is the intention of the parties that this agreement bind all parties as to all claims, including claims arising out of or relating to treatment or services provided by the health care provider including any heirs or past, present or future spouse(s) of the patient in relation to all claims, including loss of consortium. This agreement is also intended to bind any children of the patient whether born or unborn at the time of the occurrence giving rise to any claim. This agreement is intended to bind the patient and the health care provider and/or other licensed health care providers or preceptorship interns who now or in the future treat the patient while employed by, working or associated with or serving as a back-up for the health care provider, including those working at the health care provider, including those working at the health care provider’s clinic or any other clinic or office whether signatories to this form or not. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the health care provider, and/or the health care provider’s associates, association, corporation, partnership, employees, agents and estate, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress, injunctive relief, or punitive damages.

Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrate (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days thereafter. The neutral arbitrator shall then be the sole arbitrator and shall decide the arbitration. Each party to the arbitration shall pay such party’s pro rata share of the experiences and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees, witness fees, or other expenses incurred by a party for such party’s own benefit. Either party shall have the absolute right to bifurcate the issues of liability and damage upon written request to the neutral arbitrator. The parties consent to the intervention and joinder in this arbitration of any person or entity that would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration. The parties agree that provisions of state and federal law, where applicable, establishing the right to introduce evidence of any amount payable as a benefit to the patient to the maximum extent permitted by law, limiting the right to recover non-economic losses, and the right to have a judgment for future damages conformed to periodic payments, shall apply to disputes within this Arbitration Agreement. The parties further agree that the Commercial Arbitration Rules of the American Arbitration Association shall govern any arbitration conducted pursuant to this Arbitration Agreement.

Article 4: General provision: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable legal statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribes herein with reasonable diligence. Article 5: Revocation: This agreement may be revoked by written notice delivered to all health care providers within 30 days of signature and if not revoked will govern all professional services received by the patient and all other disputes between the parties. Article 6: Retroactive Effect: By typing your name below, if applicable this will also cover services rendered before the date it was signed, effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement.

NOTICE: BY SIGNING THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.

Authorization

I hereby authorize the providers at DREAM Wellness to work with me through the use of procedures and techniques he/she is certified and/or licensed and qualified for, as he/she deems appropriate. I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for all payment.

DREAM Wellness will not be held responsible for any pre-existing medically diagnosed conditions or for any medical diagnosis. I also understand that if I suspend or terminate my care, any fees for professional services rendered to me will become immediately due and payable.

I hereby authorize assignment of my insurance rights and benefits (if applicable) directly to the provider of services rendered. If I am using insurance benefits to cover the cost of my care (in full or in part), I understand that there is no guarantee that the insurance company will in fact pay my provider the expected amount for my services and the entire fee is ultimately my responsibility (unless prior arrangements have been made in writing).

If my insurance coverage or benefits change or are cancelled during my course of care, I acknowledge that it is my responsibility to inform DREAM Wellness of such changes as DREAM Wellness only verifies coverage and benefits at the beginning of care, at the beginning of each new calendar year and when requested by you.

Notice of Privacy: HIPAA

Notice of Privacy for: Patient’s Protected Health Information (HIPAA)

This office abides by the terms described in this policy.

This office uses and discloses your protected health care information for the following reasons:

• To share with other treating health care providers regarding your health care.
• To submit to insurance companies or Worker’s Compensation Claim to verify that appropriate services have been rendered.
• To determine patient’s / practice member’s benefits in a health care plan.
• Releasing information required by State or Federal Public Health law.
• To assist in overcoming a language barrier when caring for a patient / practice member.
• Business associates providing written assurances for your privacy have been attained.
• Emergency situations
• Abuse, neglect or domestic violence
• Appointment reminders to household members or answering machines
• Sign in logs may be disclosed to verify office visits
   

Any other uses or disclosures will only be made with your specific written prior authorization. 

You have the right to:

• Revoke authorization, in writing at any time by specifying what you want restricted and to whom.
• Speak to our privacy officer, who is Brian A. Stenzler, DC., and can be reached at              858-274-2225 regarding privacy issues.
• Inspect, copy and amend your protected health information and amend it as allowed by law.
• Obtain an accounting of disclosures of your protected health information.
• To render a complaint to our privacy officer or the Secretary of Health and Human Services.

This office reserves the right to change the terms of this notice and to make new notice provisions for all protected health information that it maintains.  Patients / practice members may also get an updated copy upon request at any time by asking the staff.

I acknowledge that I have read and reviewed this notice with full understanding.

Terms of Acceptance for Care 

When a practice member receives services at D.R.E.A.M. Wellness®, it is essential for all parties to be working toward the same objective.

Chiropractic has only one goal. It is important that each practice member understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment.

Adjustment: An adjustment is the specific application of forces to facilitate the body's correction of vertebral subluxation. Our Chiropractic method of correction is by specific adjustments of the spine. Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body's innate ability to express its maximum health potential.

We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a Chiropractic spinal examination, we encounter non-Chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area.

Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body's innate wisdom. Our only method is specific adjusting to correct vertebral subluxations. 

Chiropractic Informed Consent

You are the decision maker for your health care. Part of our role is to provide you with information to  assist you in making informed choices. This process is often referred to as “informed consent” and involves yourunderstanding and agreement regarding the care we recommend, the benefits and risks associated with the care, alternatives, and the potential effect on your health if you choose not to receive the care. 

We may conduct some diagnostic or examination procedures if indicated. Any examinations or tests conducted will be carefully performed but may be uncomfortable.

Chiropractic care centrally involves what is known as a chiropractic adjustment. There may be additional supportive procedures or recommendations as well. When providing an adjustment, we use our hands or an instrument to reposition anatomical structures, such as vertebrae. Potential benefits of an adjustment include restoring normal joint motion, reducing swelling and inflammation in a joint, reducing pain in the joint, and improving neurological functioning and overall well-being.

It is important that you understand, as with all health care approaches, results are not guaranteed, and there is no promise to cure. As with all types of health care interventions, there are some risks to care, including, but not limited to: muscle spasms, aggravating and/or temporary increase in symptoms, lack of improvement of symptoms, burns and/or scarring from electrical stimulation and from hot or cold therapies, including but not limited to hot packs and ice, fractures (broken bones), disc injuries, strokes, dislocations, strains, and sprains.

With respect to strokes, there is a rare but serious condition known as an “arterial dissection” that typically is caused by a tear in the inner layer of the artery that may cause the development of a thrombus (clot) with the potential to lead to a stroke. The best available scientific evidence supports the understanding that chiropractic adjustment does not cause a dissection in a normal, healthy artery. Disease processes, genetic disorders,medications, and vessel abnormalities may cause an artery to be more susceptible to dissection. Strokes caused by arterial dissections have been associated with over 72 everyday activities such as sneezing, driving, and playing tennis.

Arterial dissections occur in 3-4 of every 100,000 people whether they are receiving health care or not. Patients who experience this condition often, but not always, present to their medical doctor or chiropractor with neck pain and headache. Unfortunately a percentage of these patients will experience a stroke. The reported association between chiropractic visits and stroke is exceedingly rare and is estimated to be related in one in one million to one in two million cervical adjustments. For comparison, the incidence of hospital admission attributed to aspirin use from major GI events of the entire (upper and lower) GI tract was 1219 events/ per one million persons/year and risk of death has been estimated as 104 per one million users.

It is also important that you understand there are treatment options available for your condition other than chiropractic procedures. Likely, you have tried many of these approaches already. These options may include, but are not limited to: self-administered care, over-the-counter pain relievers, physical measures and rest, medical care with prescription drugs, physical therapy, bracing, injections, and surgery. Lastly, you have the right to a second opinion and to secure other opinions about your circumstances and health care as you see fit.

I have read, or have had read to me, the above consent. I appreciate that it is not possible to consider every possible complication to care. I have also had an opportunity to ask questions about its content, and by signing below, I agree with the current or future recommendation to receive chiropractic care as is deemed appropriate for my circumstance. I intend this consent to cover the entire course of care from all providers in this office for my present condition and for any future condition(s) for which I seek chiropractic care from this office.

24 Hour Cancellation Policy

This section is to advise you of our office’s 24 hour cancellation policy. Due to the overwhelming demand and limited appointment slots, we are unable to hold an appointment time for you if you are not able to keep it.

Giving us notice of 24 hours or more allows us the opportunity to fill the appointment time slot from the waiting list of others needing an appointment. If you need to cancel your scheduled appointment, please notify us as soon as possible, at the very latest 24 hours prior to your scheduled appointment. If you cancel an appointment with fewer than 24 hours notice, or fail to show up for your scheduled appointment, you will be charged a cancellation fee up to the amount of your scheduled service(s). (If you are scheduled for a service from a package previously purchased, you will lose that visit.)  The minimum cancellation / no show fee is $30. Each service has it's own policy and fee so please make sure you are aware of a particular service's policy prior to booking any service.

Insurance Policies

(This pertains to everyone even if not planning on using insurance at this time.)

DREAM Wellness is a not an insurance-dependent wellness center, but rather one that is focused on assisting its members bridge the gap from a reactive system of “sick care” to a proactive model of wellness care. That being said, some people utilize our services strictly for the relief of symptoms, some to correct a problem, and others (with no symptoms at all) choose to utilize our services because they understand the benefits of a wellness lifestyle.

While insurance may cover some of the services offered at DREAM Wellness, they typically cover them based on what they consider to be clinically necessary. Some insurance plans cover wellness (maintenance) care (with or w/out symptoms), some cover corrective care (with or w/out symptoms) and some only cover symptomatic relief care.

As a service to our members, we will gladly verify your insurance benefits with your carrier and do our best to see if they will cover any of the services you may receive at our center. However, when we verify, they clearly explain that whatever they tell us is not a guarantee of payment. Therefore, as a health care provider and a business, we, too, must protect ourselves to ensure that we receive payment for services rendered. When you accept care in our office, we may offer the service of filing your insurance for you. Ultimately, however, YOU are responsible for all charges on your account.

Should we file insurance claims on your behalf, we will do the best we can do to maximize your insurance benefits while maintaining honesty & integrity in the 3rd party reimbursement system. By typing your name below, YOU are agreeing on our terms on non-assignment of benefits statement.

Non-Assignment of Benefits: As a courtesy, the doctors may submit the insurance claims to my carrier and not charge me the full cost of the services up front. If DREAM Wellness is NOT an in-network (participating) provider with my insurance carrier, insurance payments for the services I received at DREAM Wellness may be sent directly to me. If so, I agree to sign over and present all insurance checks I receive to DREAM Wellness within five (5) business days of receipt. I also have the option of writing a personal check for the total amount of insurance reimbursements I receive and presenting that to DREAM Wellness within five (5) business days as an alternative. If on a pre-pay plan, DREAM Wellness will refund me any money that may be owed to me based on the plan agreement within five (5) business days. I will provide my valid credit card number and expiration date in the event that I do not turn over any and all insurance checks that I receive that are due to DREAM Wellness, and my card will be charged accordingly for those amounts. If so, I also agree that I will be charged an additional 3% of the balance to pay for credit card service fees and other administrative costs that would not have otherwise been incurred had I brought the checks in at the time of receipt.

I have read and understand the terms of the Insurance Policies and Non-Assignment of benefits. I hereby authorize DREAM Wellness to release any information to any third party payor regarding my care for the purpose of processing my claim. I authorize and request my insurance company to pay directly to DREAM Wellness any amounts that would otherwise be payable to me for the services I received. I also authorize payment to be taken directly from my credit card in the event that I do not fulfill this agreement and obligation to DREAM Wellness.

Fee Schedule and Financial Policy for Chiropractic

Our experience has shown that it is wise to have an understanding with our practice members as to our office policies and fees. Therefore, this information has been prepared for your convenience and information. We offer several methods of payment for your care at our office and you may choose the plan that you prefer. This information will enable us to better serve you and help to avoid misunderstandings in the future. Our main concern is your health and well being and we will do our best to help you.

Important: All practice members are responsible for full payment for the first visit (unless other arrangements have been made in advance.)

Insurance: We will verify all insurances and your benefits per your agreement with your carrier. Regardless of your coverage, the Doctor will give his/her recommendations and an appropriate care plan for each individual to obtain optimal results.

Payment for services rendered is ultimately YOUR responsibility. Please let the front-desk know if you have been in some type of accident or have been injured on the job. This will enable us to give you any and all information necessary to serve you completely and accurately. Many of our practice members receive our services as part of a package, hence the reason for the variation in prices. Also, fees may vary based on whether they are being paid on a cash or insurance basis. (All practice members, whether they have insurance or not, have the opportunity to receive our cash prices and may choose not to utilize their insurance coverage.)

As part of our routine care, multiple services may be performed at a single time. (When using insurance, it is common to see some of these services listed on your explanation of benefits you will receive from your carrier. If you are unclear about what service you will be personally responsible to pay, please ask the office coordinator or provider prior to receiving the service.)

Consultation: No Charge
Initial Chiropractic Exam: $50-$250
Chiropractic re-examination: $60-$90
*X-Rays (May be included in exam fee- inquire within):$50 - $175
Chiropractic Adjustments: $25 - $75
Neuromuscular Re-education, Extremity adjustment, Manual Therapy: $45

If you would like a full description of each service listed above, please ask your provider.

Agreement: By typing my name below signifies my agreement for payment in full on a cash basis if I have not provided DREAM Wellness with all necessary insurance documents and information by the time of the second visit.

*It is understood and agreed that the payments to DREAM Wellness for X-Rays is for examination of X-rays only. The X-ray negatives will remain the property of this office. They are kept on file where they may be seen at any time. If you desire a copy of your films, they will provided to you at the cost incurred to DREAM Wellness.