All information will be kept strictly confidential. Your response will help determine if chiropractic treatment will benefit you. If we do not believe your condition will respond satisfactorily, we will refer you to the appropriate physician.
Informed Consent to Care
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 your understanding 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, Dr. Wilson uses his hands 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, 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 hot or cold therapies, fractures (broken bones), disc injuries, strokes, dislocations, strains, and sprains. With respect to strokes, there is a rare but serious condition known as a cervical arterial dissection that involves an abnormal change in the wall of an artery that may cause the development of a thrombus (clot) with the potential to lead to a stroke. This occurs in 3-4 of every 100,000 people whether they are receiving chiropractic 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. As chiropractic can involve manually and/or mechanically adjusting the cervical spine, it has been reported that chiropractic care may be a risk for developing this type of stroke. The association with stroke is exceedingly rare and is estimated to be related in one in one million to one in two million cervical adjustments.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.
Billing and Privacy Practices
Notice of Insurance Billing (if applicable)As a courtesy to you, we diligently get as much complete information for you as we can from your insurance company regarding your specific plan before your visit here. This effort is an attempt to not have any “surprise” balances due from you after insurance processes the bill.It is getting more and more difficult to get a complete benefit picture at this time with the healthcare changes being implemented. Every benefit quote we get states, “a quote of benefits does not guarantee payment.” Billing of services to your insurance company does not guarantee that your plan will pay what was quoted to us. We work very hard to bill your insurance correctly and timely for the most positive result. Being familiar with your insurance plan yourself is very helpful for your scheduling and payment needs.
Financial AgreementI understand that I am ultimately responsible for all charges whether or not paid by insurance and agree to pay such charges for services rendered. I authorize the doctor to release all information to secure payment of benefits. Our office policy requires payment at the time of treatment for all cash paying, Medicare, and personal insurance patients with unmet deductibles, unless other arrangements have been made with the office manager. HIPAA Notice of Privacy PracticesI acknowledge that I have been presented with a copy of the HIPAA Notice of Privacy Practices. I am aware of the fact that I may ask for a copy of this document in writing by contacting Dr. Jared Wilson @ 8611 N Division St, Ste A, Spokane, WA 99208.I am signing this document stating that I am aware of how to obtain the information for my personal reference and that I have been presented with a master copy to read for my information. I understand who to contact and ask if I have any question regarding the HIPAA Notice of Privacy Practices.
Notice of Information PracticesWe keep a record of the health care services we provide you. You may ask us to see and copy that record. You may also ask us to correct that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so.
Thank you very much for your understanding.
I have read, or have had read to me, the above billing and privavy practice policy.