I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that Bazil Chiropractic Health Center will prepare any necessary reports and forms to
assist me in making collection from the insurance company and that any amount authorized to be paid directly to Bazil Chiropractic Health Center will be credited to my account on receipt. However, I clearly understand and agree that all
services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that I suspend or terminate my care and treatment, any fees for professional services rendered me will be immediately due
and payable.

I hereby request and consent to the performance of chiropractic adjustments and any other chiropractic procedures, including examination tests, diagnostic x-ray(s) and physical therapy techniques, on me (or on the patient named below for which I am legally responsible) which are
recommended by the doctor of chiropractic named below and/or other licensed doctors of chiropractic who now or in the future render treatment to me while employed by, working for or associated with, or serving as back-up for the doctor of chiropractic named below.

I understand that, as with any health care procedure there are certain complications, which may arise during a chiropractic adjustment. Those complications include by are not limited to: fractures, disc injuries, dislocations, muscle strain, Horner’s syndrome, diaphragmatic paralysis, cervical myelopathy and costovertebral strains and separations. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. I do not expect the doctor to be able to anticipate all risks and complications and I wish to rely on the doctor to exercise judgement during the course of the procedure(s) which the doctor feels at the time. Based upon the facts then know, are in my best interest.

 

I have had an opportunity to discuss with the doctor named below and/or with office personnel the nature, purpose and risks of chiropractic adjustments and other recommended procedures and have had my questions answered to my satisfaction. I understand that the results are not guaranteed.

 

By signing below, I state that I have weighted the risks involved in
undergoing treatment and have myself decided that it is in my best interest to undergo the chiropractic treatment recommended. Having been informed of the risks, I hereby give my consent to that treatment. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

Signing In
When you arrive, sign in. You will be called and assigned a treatment area in the order you signed in for the Doctor. On each visit, pick up your card at the front desk, go to the assigned treatment area and lie face down. Rest and relax, the Doctor will be in as soon as possible.

New Patient Orientation
It is the policy of this office that you, the patient, participate in your recovery. It is mandatory that all patients attend our Patient Orientation as soon as possible after starting care. This class explains how the body functions, how Chiropractic works, and how results are produced. Family and friends are always welcome. There is no charge for the class. While children are welcome in the office during our regular treatment times, child care is not available during our evening classes, so it is important that other arrangements are made for children under the age of 12
during the Patient Orientation.

Missing or Changing Appointments
The Doctor has set up a specific course of treatment for you. A certain number of treatments in a set amount of time are required to get the results we both desire. Thus, if you need to change the time of your appointment plan to come another time the same day or, if the same day is not possible, it is important that you make up missed appointments within one week. If you want to be here and have your spine corrected, you will be expected to follow the Doctor’s treatment recommendations. There will be no exceptions to this. If you are not ready to make your health a priority by making a commitment to your treatment, then do not waste your time and money and plan to have your spine corrected at a later date. SCHEDULE YOUR LIFE AROUND YOUR HEALTH, NOT YOUR HEALTH AROUND YOUR LIFE.

Appointment Times
We will set a specific time for your adjustment. Try to be prompt as the Doctor has set this time aside to detect and correct vertebral subluxations and during this time that is all he will do. If you come at another time, you may have to wait a few minutes, as the Doctor also set aside specific times to see new patients and conduct extended consultations. We value your time and do not want you to wait needlessly. If you wish to sit down with the Doctor to discuss your
case, a specific Doctor/Patient conference can be arranged at no additional charge.

Payment of Bills
We will expect you to honor the financial agreement you make with our office. In order to serve you better, please plan to make any payments from care, a three-month time period is allowed for settlement of adjustment. If settlement has not been reached within this time period, or if you have suspended or terminated your care without your Doctor’s approval, payment for
services is due immediately.

Progress Evaluations and Re-Examinations
During your treatment series, re-examinations and progress will be done on a regular basis.

Communication

Please communicate directly to your Doctor any upsetting matter such as waiting too long, rudeness by any staff member, failure to understand treatment, need for extended consultation, etc. We are here to serve you. Your criticism will help us to help you as well as others.

Cash Patient Financial Policy
We request that 100% of the first visit be paid at the time of the first visit. For your
convenience, future payments may be arranged at the first visit of each week. We are happy to accept your check or credit cards.

Major Medical/Group Insurance
You are expected to make a payment toward your services on the first day in this office. Complete the information on the “Chiropractic Insurance Policy” sheet. Bring it with you to your next visit. Also, any checks sent to your home by the insurance company must be brought or sent to our office within three days.

Auto Accident/Personal Injury
You are usually covered 100% for these injuries. You are responsible for reporting your accident to the insurance company and your insurance agent.

Worker’s Compensation

If your care is related to Worker’s Compensation, you must obtain written consent from your employer allowing you to receive care at our office. Also, you must request that your employer notify his insurance company that you are under care at our office and have them send the appropriate forms to our office immediately.

Medicare
Medicare will cover a portion of your visits after your deductible is met. Medicare does not pay for examinations or x-rays. Once Medicare benefits are exhausted, you are responsible for payment. Don’t hesitate to ask your insurance coordinator about special payment plans for which you might be eligible.

If you understand the above policy and agree to abide by it, please sign down below. 

To Patients:

 Dr. Sladich is a Certified Radiologist, as well as, a Doctor of Chiropractic. Dr. Sladich provides a biomechanical viewpoint of skeletal radiology that is absolutely necessary in order for a Doctor of Chiropractic to perform chiropractic treatment correctly. Dr. Rangel’s expertise in radiological interpretation is crucial in obtaining the proper diagnosis and the proper treatment for patients at our health center.

If Dr. Bazil requests that you submit to x-rays, these x-rays will become part of your permanent medical records and will be maintained whether by our office or the facility at which they were taken. The patient can have these x-rays transferred to another health care provider, for a limited time, for the purpose of review. If the patient so desires, the patient can pay to have copies made from the original x-rays for their own records.

I have read the above and agree to sign:

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

This Practice is committed to maintaining the privacy of your protected health information ("PHI"), which includes information about your health condition and the care and treatment you receive from the Practice.
The creation of a record detailing the care and services you receive helps this office to provide you with quality health care. This Notice details how your PHI may be used and disclosed to third parties. This Notice also details your rights regarding your PHI. The privacy of PHI in patient files will be protected when the files
are taken to and from the Practice by placing the files in a box or brief case and kept within the custody of a doctor or employee of the Practice authorized to remove the files from the Practice’s office.
NO CONSENT REQUIRED

 The Practice may use and/or disclose your PHI for the purposes of:
(a) Treatment - In order to provide you with the health care you require, the Practice will provide your PHI to those health care professionals, whether on the Practice's staff or not, directly involved in your care so that they may understand your health condition and needs.

(b) Payment - In order to get paid for services provided to you, the Practice will provide your PHI, directly or through a billing service, to appropriate third party payers, pursuant to their billing and payment requirements.

(c) Health Care Operations - In order for the Practice to operate in accordance with applicable law and insurance requirements and in order for the Practice to continue to provide quality and efficient care, it may be necessary for the Practice to compile, use and/or disclose your PHI. The Practice may use and/or disclose your PHI, without a written Consent from you, in the following additional instances:

(a) De-identified Information - Information that does not identify you and, even without your name, cannot be used to identify you.

(b) Business Associate - To a business associate if the Practice obtains satisfactory written assurance, in accordance with applicable law, that the business associate will appropriately safeguard your PHI. A business associate is an entity that assists the Practice in undertaking some essential function, such as a billing company that assists the office in submitting claims for payment to insurance companies or other payers.

(c) Personal Representative - To a person who, under applicable law, has the authority to represent you in making decisions related to your health care.

(d) Emergency Situations -
• (i) for the purpose of obtaining or rendering emergency treatment to you provided that the Practice attempts to obtain your Consent as soon as possible; or
• (ii) to a public or private entity authorized by law or by its charter to assist in disaster relief efforts, for the purpose of coordinating your care with such entities in an emergency situation.

(e) Communication Barriers - If, due to substantial communication barriers or inability to communicate, the Practice has been unable to obtain your Consent and the Practice determines, in the exercise of its professional judgment, that your Consent to receive treatment is clearly inferred from the circumstances.

(f) Public Health Activities - Such activities include, for example, information collected by a public health authority, as authorized by law, to prevent or control disease and that does not identify you and, even without your name, cannot be used to identify you.

(g) Abuse, Neglect, or Domestic Violence - To a government authority if the Practice is required by law to make such disclosure. If the Practice is authorized by law to make such a disclosure, it will do so if it believes that the disclosure is necessary to prevent serious harm.

(h) Health Oversight Activities - Such activities, which must be required by law, involve government agencies and may include, for example, criminal investigations, disciplinary actions, or general oversight activities relating to the community's health care system.

(i) Judicial and Administrative Proceeding - For example, the Practice may be required to disclose your PHI in response to a court order or a lawfully issued subpoena.

(j) Law Enforcement Purposes - In certain instances, your PHI may have to be disclosed to a law enforcement official. For example, your PHI may be the subject of a grand jury subpoena. Or, the Practice may disclose your PHI if the Practice believes that your death was the result of criminal conduct.

(k) Coroner or Medical Examiner - The Practice may disclose your PHI to a coroner or medical examiner for the purpose of identifying you or determining your cause of death.

(l) Organ, Eye, or Tissue Donation - If you are an organ donor, the Practice may disclose your PHI to the entity to whom you have agreed to donate your organs.

(m) Research - If the Practice is involved in research activities, your PHI may be used, but such use is subject to numerous governmental requirements intended to protect the privacy of your PHI and that does not identify you, even without your name, cannot be used to identify you.

(n) Avert a Threat to Health or Safety - The Practice may disclose your PHI if it believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and the disclosure is to an individual who is reasonably able to prevent or lessen the threat.

(o) Workers' Compensation - If you are involved in a Workers' Compensation claim, the Practice may be required to disclose your PHI to an individual or entity that is part of the Workers' Compensation system.

 Appointment Reminders
*Your health care provider or a staff member may disclose your health information to contact you to provide appointment reminders. If you are not at home to receive an appointment reminder, a message will be left on your answering machine, voice mail, or with the person who answers the call.

*You have the right to refuse us authorization to contact you to provide appointment reminders. If you refuse us authorization, it will not affect the treatment we provide to you.

 Sign-in Log
This Practice maintains a sign-in log for individuals seeking care and treatment in the office. This sign-in sheet is located in a position where staff can readily see who is seeking care in the office, as well as the individual's location within the Practice's office suite. This information may be seen by, and is accessible to, others who are seeking care or services in the Practice's offices.

Family/Friends
The Practice may disclose to your family member, other relatives, a close personal friend, or any other person identified by you, that your PHI is directly relevant to such person's involvement with your care or the payment for your care unless you direct the Practice to the contrary. The Practice may also use or disclose your PHI to notify or assist in the notification (including identifying or locating) a family member, a personal representative, or another person responsible for your care, of your location, general condition or death. However, in both cases, the following conditions will apply:

• (a) If you are present at or prior to the use or disclosure of your PHI, the Practice may use or disclose your PHI if you agree, or if the Practice can reasonably infer from the circumstances, based on the exercise of its professional judgment that you do not object to the use or disclosure.

• (b) If you are not present, the Practice will, in the exercise of professional judgment, determine whether the use or disclosure is in your best interests and, if so, disclose only the PHI that is directly relevant to the person's involvement with your care.

AUTHORIZATION
Uses and/or disclosures, other than those described above, will be made only with your written Authorization.

Your Right to Revoke Your Authorization
You may revoke your authorization to us at any time; however, your revocation must be in writing.

Restrictions

You may request restrictions on certain use and/or disclosure of your PHI as provided by law. However, the Practice is not obligated to agree to any requested restrictions. To request restrictions, you must submit a written request to the Practice's Privacy Officer. In your written request, you must inform the Practice of
what information you want to limit, whether you want to limit the Practice's use or disclosure, or both, and to whom you want the limits to apply. If the Practice agrees to your request, the Practice will comply with your request unless the information is needed in order to provide you with emergency treatment.

You Have a Right to

Inspect and obtain a copy of your PHI as provided by 45 CFR 164.524. To inspect and copy your PHI, you are requested to submit a written request to the Practice's Privacy Officer. The Practice can charge you a fee for the cost of copying, mailing, or other supplies associated with your request. Receive confidential communications or PHI by alternative means or at alternative locations. You must make your request in writing to the Practice's Privacy Officer. The Practice will accommodate all reasonable requests. Prohibit report of any test, examination, or treatment to your health plan or anyone else for which you pay in cash or by credit card.

Receive an accounting of disclosures of your PHI as provided by 45 CFR 164.528. The request should indicate in what form you want the list (such as a paper or electronic copy) Receive a paper copy of this Privacy Notice from the Practice upon request to the Practice's Privacy Officer. Request copies of your PHI in electronic format if this office maintains your records in that format.

Amend your PHI as provided by 45 CFR 164.528. To request an amendment, you must submit a written request to the Practice's Privacy Officer. You must provide a reason that supports your request. The Practice may deny your request if it is not in writing, if you do not provide a reason in support of your request, or if the information to be amended was not created by the Practice (unless the individual or entity that created the information is no longer available), if the information is not part of your PHI maintained by the Practice if the information is not part of the information you would be permitted to inspect and copy, and/or if the information is accurate and complete. If you disagree with the Practice's denial, you will have the right to submit a written statement of disagreement. Receive notice of any breach of confidentiality of your PHI by the Practice Complain to the Practice or to the Office of Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F, HHH Building, Washington, D.C. 20201, 202 619-0257, email: ocrmail@hhs.gov if you believe your privacy rights have been violated. To file a complaint with the Practice, you must contact the Practice's Privacy Officer. All complaints must be in writing. I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read them or declined the opportunity to read them and understand the Notice of Privacy Practices. I understand that this form will be placed in my patient chart and maintained for six years.

 PRACTICE'S REQUIREMENTS
1. The Practice:
• Is required by federal law to maintain the privacy of your PHI and to provide you with this Privacy Notice detailing the Practice's legal duties and privacy practices with respect to your PHI.
• Is required to abide by the terms of this Privacy Notice.
• Reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice provisions effective for your entire PHI that it maintains.
• Will distribute any revised Privacy Notice to you prior to implementation.
• Will not retaliate against you for filing a complaint.

Notice of Privacy Practices explaining:

How this office will use and disclose my protected health information. My privacy rights with respect to my protected health information. This office’s obligation is concerning the use and disclosure of my protected 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 upon request.

I also understand that if I have any questions or complaints, I may contact the U.S. Department of Health and Human Services.

We would like to take a moment to welcome you to our office and to assure you that you will be receiving the very best care available for your condition. To familiarize you with the financial policies of our office, I would like to explain how your medical bills will be handled.

PAYMENT ARRANGEMENTS

We accept cash, checks, or credit card as payment for services rendered. It is our policy in this office to maintain your account on a current basis. Charges for treatment are due at the time the service is provided. An interest charge of 5% per month may be applied to all past due balances. Once your initial examination is complete, the Doctor will specify a treatment program for your condition(s). Our office does offer savings plans for pre-payment and these will be explained to you following your report of findings. If this arrangement becomes inconvenient for you, please see our office manager so that other arrangements can be made.

VOLUNTARY TERMINATION OF CARE

It is also the policy of this office that if you should choose to suspend or terminate your care and treatment, any outstanding fees for professional services rendered to you will be immediately due and payable. We hope that this has answered any questions you might have regarding your financial arrangements. Once again, we’d like to welcome you to our office. If, at any time, you have any questions about your care, please don’t hesitate to ask.

I have read and agree to the above,

Dear Patient,

We strive to provide excellent spinal care for you, your family, and all of our patients. In order to do so effectively and efficiently, we have developed an appointment system that sets aside ample time for each individual patient. "No-shows", late cancellations, and appointment lateness inconvenience those individuals who need access to spinal care in
a timely manner.

In an effort to reduce the number of such occurrences, we have implemented an
Appointment Cancellation Policy and it is effective immediately. Our policy is as follows:

We request you give our office a 24- hour notice in the event you need to
reschedule your appointment. Our phone number is (714) 375-5864.

If you are more than 10 minutes late, we reserve the right to cancel your
appointment and reschedule to a different time that day or to a different
day altogether. 

Our office sends out reminder texts for appointments. If we have your email on file, you will receive e-mail reminders as well. It is ultimately the patient’s responsibility to remember their scheduled appointments. We thank you for trusting Bazil Chiropractic Health Center with your spinal care. I have read and understand the Appointment Cancellation Policy and agree to the terms
of this policy.

At Bazil Chiropractic Health Center our massage appointments are by appointment only. Please talk to our front desk to check for availability and to schedule an appointment with Massage Therapist. To ensure appointment availability, Bazil Chiropractic Health Center suggests a regular series of appointments be scheduled.

SCHEDULED MASSAGE TIME
There is a set-up time and break-down time included in the 30 or 60-minute massage to ensure the quality and cleanliness of the massage room before you come in to receive the service.

CANCELLATION POLICY
Our time together is important. Unless there is an emergency, it is requested that you cancel your appointment 24 hours in advance or pay the missed appointment fee in full of $10.00.

LATENESS POLICY
We request that you arrive early for your appointment. Our massage therapy lateness policy is this: if you arrive late for your appointment, the time left will be used to its best advantage.

SICKNESS POLICY
Massage therapy recognizes that both massage therapists and patients are vulnerable to infections and therefore ask patients to cancel appointments when they are feeling unwell. If you have any of the following contagious illnesses the massage session will be rescheduled: Vomiting, Fever, Diarrhea, Chicken pox, Measles, Mumps, Meningitis, Hepatitis A, Conjunctivitis, Rubella, Head Lice, Impetigo, Influenza, Meningococcal Disease, Polio, Ringworm of the Body,
Feet, or Scalp; Scabies, Thrust, Whooping Cough, Common Cold

INFORMED CONSENT
I have read the above explanation of the massage therapy protocol of Bazil Chiropractic Health Center. By signing below, I state that I fully understand the Massage Therapy Appointment(s) Agreement. I also understand that by signing the Massage Therapy Appointment(s) Agreement, that I will abide by this
agreement for all future massages to be received by Bazil Chiropractic Health Center.

We would like to know how much your pain presently prevents you from doing what you would normally do. Regarding each category, please indicate the overall impact your present pain has on your life, not just when the pain is at its worst.

Please circle the number which best describes how your typical level of pain affects these six categories of activities.