Consent For Treatment

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1. CONSENT FOR TREATMENT: I hereby agree to the performance of such examinations, procedures and/or treatment as in the opinion of the attending health care professional, and/or licensed health care contractee or employee is/are deemed necessary on the patient named above. If the patient is a minor, I hereby certify that I am either the parent or legal guardian of the above named and hereby grant consent for treatment and request for services as aforementioned. I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic x-rays, and any supportive therapies on me (or on the patient named below, for whom I am legally responsible) by the doctor of chiropractic indicated below and/or other licensed doctors of chiropractic and support staff who now or in the future treat me while employed by, working or associated with or serving as back-up for the doctor of chiropractic named below, including those working at the clinic or office listed below or any other office or clinic, whether Signatories to this form or not. I have had an opportunity to discuss with the doctor of chiropractic named below and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and procedures. I understand that results are not guaranteed. I understand and am informed that, as in the practice of medicine and like all other health modalities, results are not guaranteed, and there is no promise of cure. I further understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are somerisks to treatment, including, but not limited to, fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known, is in my best interests. I further understand that there are treatment options available for my condition other than chiropractic procedures. These treatment options include, but not limited to, self-administered, over-the-counter analgesics and rest; medical care with prescription drugs such as anti-inflammatories, muscle relaxants and painkillers; physical therapy; steroid injections; bracing; and surgery. I understand and have been informed that I have the right to a second opinion and to secure other opinions if I have concerns as to the nature of my symptoms and treatment options.

2. RELEASE OF INFORMATION: To the extent necessary to determine liability for payment and to obtain reimbursement, the health care professional may disclose portions of the patient’s record, to any person or corporation which is or may be liable, for all or any portion of the health care professional’s charge, including but not limited to insurance companies, health care service plans or workers’ compensation carries. I hereby state and agree that a photocopy and/or fax of this document will be as valid and binding on all parties involved as the original copy for this document.

3. INSURANCE ASSIGMENT: I do hereby assign irrevocable direct payment to the health care professional, and any contractees, the health care benefits due for the total charges or payment equal to the reimbursement rate, as may be appropriate, for any services rendered. I understand that I am financially responsible to the health care professionals and any other contractee, for services not covered by this assignment. I hereby instruct and direct any obligated company or individual to pay by check made out and mailed directly to the above noted provider.

4. FINANCIAL AGREEMENT: I agree, whether I am signing as agent or as patient, that in consideration of the services to be rendered to the patient, I individually obligate myself to pay the account of the health care professional in accordance with the regular rates and terms of the health care professionals. I understand that the health care professional shall have the right at any time to refuse to admit me or to provide health care or treatment for me. The health care professional, as a courtesy to the patient, agrees to extend credit by awaiting payment from the insurance company, provided any deductible and co-payment are paid on a weekly basis, for no longer than 60 days from the date of services at which time the account is due and payable. If the patient should discontinue treatment against the recommendations of the health care professional, then the entire balance is due and payable immediately. Should the account be referred to an attorney for collection or to a collection agency, the undersigned shall pay actual attorney’s fee and collection expenses. All delinquent accounts shall be charged a one and one-half percent interest charge per month or at the legal rate. The health care professional reserves the right to charge for a missed appointment fee if there is not at least a 24 hours cancellation notice prior to the appointment (office policy is approximately three-fourths of the average visit fee for no-show). There will be a $15.00 charge for returned checks. I further agree that the above mentioned health care provider be given irrevocable Power of Attorney to endorse/sign my name on any checks for payment of my health care professional’s bills. The health care professional can assume no responsibility for guaranteeing covered charges as billed. Should an overpayment be made, a refund check will be sent to the authorized party that is the overpayment. The health care professional reserves the right to have billing services performed by a contractual billing service.

5. AUTHORIZATION: I hereby authorize the health care professional to verify that all information provided by the patient is correct. Furthermore, if deemed necessary, I authorize the health care professional to obtain a credit report on me. I hereby agree to provide additional information that the health care professional may require prompt, including any change of address.

6. ARBITRATION AGREEMENT: 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.

7. MEDICARE NON-COVERED SERVICES: The only chiropractic service that Medicare will pay for A2000 (manipulation of the spine) up to 12 visits per year. Other chiropractic services, such as exams, x-rays, physiotherapy, supplies, vitamin supplements, etc., are not covered by Medicare. Payment for these and other services are the patient’s responsibility.

ARBITRATION AGREEMENT

Article1: Agreement to Arbitrate: It is understood that any dispute as to medical services rendered under this contract were unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California provides for judicial review of arbitration 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 intention of the parties that this agreement bind all parties whose claims may arise out of or relate 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 back-up for the health care provider, including those working at the health care provider’s clinic or office 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 loss of consortium, wrongful death, emotional stress or punitive damages. Filling of any action in any court by the health care provider to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any claim against the health care provider, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration.

Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (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 expenses and fees of the neutral arbitrator together with other expenses of the arbitration 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 the provisions of the California Medical Injury Compensation Reform Act shall apply to disputes within this Arbitration Agreement including, but not limited to, sections establishing the right to introduce evidence of any amount payable as a benefit to the patient as allowed by law (Civil Code 3333.1), the limitation on recovery for non-economic losses (Civil Code 3333.2) and the right to have a judgment for future damages conformed to periodic payments (CCP 667.7). 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 Provisions: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one processing. 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 California statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein wit reasonable diligence.

Article 5: Revocation: This agreement may be revoked by written notice delivered to the health care provider within 30 days of signature and if not revoked will govern all professional services received by the patient.

Article 6: Retroactive Effect: If patient has an occurrence this agreement covers services rendered before the date it is signed (for example, emergency treatment) under justice for health. 

The undersigned certifies that he/she has read and understood the foregoing, is entitled to a copy of same upon request, and is the patient, or is duly authorized as the patient’s general agent to execute the above and accept its items. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing I agree to the above-named procedures. 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.

WELUVUS APOTHECARY PRACTICIONERS:  KERSTIN MARIE WHEALE OR DR.NICOLAS VALLEJOS, D.C.