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I have reach and give my informed consent for treatment.
Informed consent for your chiropractic care is a process and dialogue with your chiropractic physician about the risk and benefits of proposed treatment, and other available treatment options, to allow you to participate in and make knowledgeable decisions about your chiropractic care. It is very important that you, the patient, read this document in its entirety. As a patient, it is essential that you knowledgeably participate in decisions concerning the nature and course of your chiropractic treatment. It is essential that you ask questions and receive sufficient information form your chiropractic physical about the potential risks, proposed benefits and alternatives to your proposed chiropractic treatment plan. Please DO NOT SIGN this document until you have had the opportunity to ask questions about your care and fully understand the care to be rendered, and have read this document in its entirety.
The practice of chiropractic medicine includes many standard examination and testing procedures. These may include a physical exam, orthopedic and neurological testing, paWe Optimize Wellnessation specialized instrumentation, laboratory tests, radiology exams, physical therapy modalities and rehabilitative procedures, among others.
The primary therapy utilize in your chiropractic treatment will be spinal manipulative therapy or adjustments. There are a number of different adjusting techniques, some utilizing specially designed equipment. Adjustments are usually performed by hand, but may be performed by hand-guided instruments.
Chiropractic treatment, including spinal adjustment, has been the subject of government reports and multi-disciplinary studies conducted over many years and has been demonstrated to be an effective treatment for many neck and back conditions involving pain, numbness, muscle spasm, loss of mobility, headaches and other similar symptoms. Routine chiropractic treatment can result in better function, improved joint motion, and a healthier, more active lifestyle.
A chiropractic adjustment is the application of a quick precise movement to a specified contact point of a vertebrae or other joint. Joint function can be compromised in a number of ways and can affect a patients overall health. Chiropractic manipulations or adjustments are utilized by chiropractors to restore or improve joint function. Chiropractic manipulation or adjustment may cause an audible “pop” or “click”, similar to what you have experienced when you “crack” your knuckles. You may also feel as sense of movement at the area adjusted.
There are some risks associated with chiropractic adjustments, including, but not limited to the possibility of sprains, dislocations and fractures. In addition:
1. While rare, some patients may experience short term aggravation of symptoms, rib fractures or muscle and ligament strains or sprains as a result of manual therapy techniques.
2. There are reported cases of stroke associated with neck movements including adjustments of the upper cervical spine. Current medical and scientific evidence does not establish a definite cause and effect relationship between upper cervical spine adjustment and the occurrence of stroke. Furthermore, the apparent association is noted very infrequently. However, you are being warned of this possible association because a stroke may cause serious neurological impairment and result in injuries including paralysis.
3. There are reported cases of disc injuries following cervical and lumbar spinal adjustments or chiropractic treatment.
The risk of injuries or complications from chiropractic treatments are substantially lower than that associated with many medical or other treatments, medications, and surgical procedures given for the same treatments.
Common alternatives to adjustments and manipulations include medications, physical therapy, other medical treatments and surgery provided by physicians and surgeons.
Cold Laser Treatment
Laser therapy is a safe, non-invasive, FDA cleared modality for the treatment of pain and the temporary increase of microcirculation. Increased microcirculation can provide relief for many acute and chronic conditions. Laser therapy utilizes visible and invisible laser radiation, therefore, appropriate eye protection is required at all times during treatment.
Effects of your treatment will continue for up to 18 hours. Individuals respond uniquely to treatment, you may see immediate results after the first treatment or depending on the severity of your condition you may require several treatments before you begin to feel results.
Increased soreness may occur after your first laser session. This is a normal healing phenomenon known as retracing. Mild bruising may occur from the soft tissue manual therapy element of your treatment program.
Patient understands that the coaching services they will be receiving from us are not offered as a substitute for professional mental health care or medical care and are not intended to diagnose, treat or cure any mental health or medical conditions.
Patient also understand that we are not acting as a mental health counselor.
Patient understands and agrees that they are fully responsible for their well-being during their sessions, and subsequently, including their choices and decisions.
Patient understands that the services are not a substitute for counseling, psychotherapy, psychoanalysis, mental health care or substance abuse treatment, and Patient will not use it in place of any form of therapy.
Patient understands that all comments and ideas offered by us are solely for the purpose of aiding them in achieving their defined goals. Patient has the ability to give their informed consent, and hereby give such consent to We Optimize Wellness to assist them in achieving such goals.
Patient understands that We Optimize Wellness will protect Patient’s information as confidential unless they state otherwise in writing. If Patient reports child, elder abuse or neglect or threaten to harm themself or someone else, they understand that necessary actions will be taken and We Optimize Wellness’s confidentiality agreement is limited in this capacity. Furthermore, if We Optimize Wellness is ordered by a court to provide information or to testify, they will do so to the extent the law requires.
Patient understands that the use of technology is not always secure and they accept the risks of confidentiality in the use of email, text, phone, video conference and other technologies.
Nutritional Informed Consent
Craig Abrams, D.C.
4424 Jasmine Ave Culver City CA 90232
According to the Federal Food, Drug, and Cosmetic Act, as amended Section 201 (g) (1), the term “DRUG” is defined to mean: “Articles intended for use in the Diagnosis, Cure, Mitigation, Treatment or Prevention
A vitamin is not a drug, NEITHER is a Mineral, Trace Element, Amino Acid, or Herb Although a Vitamin, a Mineral, Trace Element, Amino Acid, or Herb may have an effect on any disease process or symptoms, this does not mean that it can be misrepresented, or be classified as a drug by anyone.
Therefore, please be advised that any suggested nutritional advice or dietary advice is not intended as a primary treatment and/or therapy for any disease or particular bodily symptom. Nutritional counseling, vitamin recommendations, nutritional advice, and the adjunctive schedule of nutrition is provided solely to upgrade the quality of foods in the patient’s diet in order to supply good nutrition supporting the physiological and biomechanical processes of the human body. Nutritional advice and nutritional intake may also enhance the stabilization of chiropractic adjustments and restorative treatment.
Availability and Nature of Other Treatment Options
Other treatment options for you condition may include:
• Self-administered, over-the-counter analgesics and rest
• Medical care and prescription drugs such as anti-inflammatory, muscle relaxants and pain killers
If you choose to use any other treatment option noted above, you should be aware that there are risks and benefits of such options and you may wish to discuss these with your primary medical physician.
Risk and Dangers of Remaining Untreated
Remaining untreated may result in persistent or increasing pain or other symptomatology, increase loss of function, formation of adhesions contributing to a pain reaction further reducing mobility, or worsening of your condition. Over time, if you choose to remain untreated, this may complicate future treatment, and make future treatment more difficult and less effective the longer treatment is postponed.
By signing this Informed Consent, I acknowledge that I have discussed, or have had the opportunity to discuss, with my Doctor of Chiropractic the nature and purpose of these treatments in general and my treatment in particular (including spinal adjustments), the benefits, risks and alternatives to chiropractic treatment.
I consent to the chiropractic treatments offered or recommended to me by my Doctor of Chiropractic, including spinal adjustments. I intend this consent to apply to all my present and future chiropractic care received by We Optimize Wellness.
Patient’s agreement to these terms shall be signified by their digital signature on this agreement. Patient will not use the lack of hand-written signature as a defense to this waiver.
Privacy Notice & Disclosure
I understand and agree to the patient privacy notice that was presented to me. I also acknowledge that a copy will be made available if I request one.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED BY WE OPTIMIZE WELLNESS AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
If you have any questions about this Notice, please contact your local facility.
Who Will Follow This Notice?
1. We Optimize Wellness;
2. Doctors of Chiropractic who provide services to you at any location; and
3. All employees and subcontractors of We Optimize Wellness.
We understand that medical information about you and your health is personal and we are committed to protecting this information. When you receive chiropractic treatment from us, a record of the treatment you receive is made. Typically, this record contains your treatment plan, your history and physical, any x-ray and test results that you provide to us, and billing record. This record serves as a:
1. Basis for planning your treatment;
2. Means of communication for or between We Optimize Wellness clinic doctors and staff, the doctors and staff of other clinics operating under We Optimize Wellness name, We Optimize Wellness by Craig Abrams Chiropractic Inc. and your other health care providers, if any, that you wish us to share them with; and a
3. Tool for assessing and continually working to improve the care rendered.
This Notice tells you the ways we may use and disclose your Protected Health Information (referred to herein as “medical information”). It also de- scribes your rights and our obligations regarding the use and disclosure of medical information.
OUR RESPONSIBILITIES We are required by law to:
1. Maintain the privacy and security of your medical information;
2. Provide you with notice of our legal duties and privacy practices with respect to information we collect and maintain about you;
3. Abide by the terms of this notice; and
4. Notify you if we are unable to agree to a requested restriction.
The Methods in Which We May Use and Disclose Medical Information about You
The following categories describe different ways we may use and disclose your medical information. The examples provided serve only as guidance and do not include every possible use or disclosure.
1. For Treatment. We will use and disclose your medical information to provide, coordinate, or manage your chiropractic treatment at this clinic or any other We Optimize Wellness clinic where you seek treatment. For example, we may share your information with your primary care physician or other specialists upon request.
2. For Payment. We will use and disclose medical information about you so that payment for the treatment you receive may be collected from you or another party.
3. For Health Care Operations. We may use and disclose medical information about you for our office operations. These uses and disclosures are necessary to run the clinic in an efficient manner and provide that all patients receive quality care. For example, your medical records may be used in the evaluation of services, and the appropriateness and quality of chiropractic treatment we provide. Chiropractic services will be provided in an open room where other patients are also receiving care. Other persons in the office may overhear some of your protected medical information during the course of care. Should you need to speak with the doctor at any time in private, a place for these conversations will be provided upon request. To the extent permitted by law, we may use cameras or other recording devices in our clinics. Any clinics having cameras or recording devises will have a notice posted at the clinic informing you of the use of such devices.
4. For Contacting You. We may use your address, phone number, e-mail and clinical records to contact you with notifications, text messages, birthday and holiday related messages, billing inquiries, information about treatment alternatives, or other health related information. If contacting you by phone, we may leave a message on your answering machine or voicemail.
5. Appointment Reminders. We may use and disclose medical information to remind you of an appointment, if applicable.
6. As Required by Law. We will disclose medical information about you when required to do so by federal or state laws or regulations.
7. Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. Health oversight agencies include public and private agencies authorized by law to oversee the health care system. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, eligibility or compliance, and to enforce health-related civil rights and criminal laws.
8. Lawsuits and Disputes. If you are involved in certain lawsuits or administrative disputes, we may disclose medical information about you in response to a court or administrative order.
9. Law Enforcement. We may release medical information if asked to do so by a law enforcement official in response to a court order or subpoena.
10. Electronic Disclosure. We may use and disclose your medical information electronically. For example, your medical information is maintained on an electronic health record. If another provider requests a copy of your medical record for treatment purposes, we may forward such record electronically.
DISCLOSURES REQUIRING AUTHORIZATION
1. Marketing. Marketing generally includes a communication made to describe a health-related product or service that may encourage you to purchase or use the product or service. We will obtain your written authorization to use and disclose your medical information for marketing purposes unless the communication is made face-to-face, involves a promotional gift of nominal value, or otherwise permitted by law. All other uses and disclosures of your information for marketing purposes require your written authorization. You have the right to revoke such authorization in writing.
YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION
You have the following rights regarding medical information collected and maintained about you:
1. Right to Inspect and Copy. The right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to us. You can also ask to see or get an electronic copy of health information we have about you. Ask us how to do this.
2. Right to Amend. If you feel that medical information maintained about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by us. To request an amendment, your re- quest must be made in writing and submitted to us. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
• Was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
• Is not part of the medical information kept by us;
• Is not part of the information which you would be permitted to inspect and copy; or
• Is accurate and complete.
3. Right to an Accounting of Disclosures. To request an “accounting of disclosures.” This is a list of the disclosures made of your medical information for purposes other than treatment, payment, or health care operations. To request this list you must submit your request in writing to us. Your request must state a time period, which may not be longer than six (6) years. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a 12-month period will be free.
4. Right to Request Restrictions. To request a restriction or limitation on the medical information we, other We Optimize Wellness clinics. uses or discloses about you for treatment OR payment. You also have the right to request a limit on the medical information we, any We Optimize Wellness clinic discloses about you to someone who is involved in your care or the payment for your care. Neither we, nor any We Optimize Wellness clinic or We Optimize Wellness are required to agree to your request, but should any of us agree to your request, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions you must make your request in writing and include (1) what information you want to limit; (2) whether you want to limit our use and/or disclosure; and (3) to whom you want the limits to apply.
5. Right to Revoke an Authorization. There are certain types of uses or disclosures that require your express authorization. For example, we, other We Optimize Wellness clinics may not sell your information to a third party for marketing purposes without first obtaining your authoriza- tion. If you provide authorization for a particular use or disclosure of your medical information, you may revoke such authorization in writing by contacting us. We will honor your revocation except to the extent that we have already taken action in reliance of the specific authorization.
6. Right to Receive a Copy of this Document. You have a right to obtain a paper copy of this document upon request.
CHANGES TO THIS NOTICE
We reserve the right to change our practices and to make the new provisions effective for all medical information we maintain. Should our information practices change, we will post the amended Notice of Privacy Practices in our office and on our website. You may request that a copy be provided to you by contacting us.
I understand and agree to the patient privacy notice that was presented to me. I also acknowledge that a copy will be made available if I request one.
Patient’s agreement to this notice shall be signified by their digital signature. Patient will not use the lack of hand-written signature as a defense to this waiver.
Patient Financial Policy
I have read and agree to the financial policy.
Please be aware We Optimize Wellness is an OUT-OF-NETWORK provider. Payment is required at the time of service. You will be provided a superbill upon request that you can submit to your insurance or medical savings plan to seek out-of-network reimbursement.
Some insurance carriers have a cap on reimbursement as well as sessions provided. It is your responsibility to understand your coverage for out-of-network providers.
At the time of your first visit we will take your credit card information for billing any unpaid balances. You will be charged for all missed appointments not cancelled twenty-four (24) hours in advanced.
Your signature below signifies that you understand our financial policy and your responsibilities regarding chargers incurred in this office. Patient’s agreement to this notice shall be signified by their digital signature. Patient will not use the lack of hand-written signature as a defense to this waiver.
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