I hereby authorize the doctor to examine me and to perform any necessary diagnostic procedures to fully evaluate my condition for the presence of vertebral subluxations and if necessary render Chiropractic services to me. By signing below, I state that I have weighed the risks involved in undergoing treatment and have, myself, decided that it is in my best interest (or said minor's interest) to undergo the treatment recommended. I acknowledge that no guarantee as to the results that may be obtained. I also understand that I am responsible for all charges.
Consent to Examination and Treatment: I give the doctors and staff of Ride Balanced PLLC permission to perform all examinations, x-rays, and treatments deemed necessary by the doctor. I understand that some of these procedures may be performed by either the staff or doctor.
HIPPA: A copy of the full Health Information Privacy Policy for our office can be requested at the front desk. In brief, it states as our patient your privacy is protected. By signing you are stating that you understand that Ride Balanced PLLC may use or disclose your protected health information for treatment, payment or health care operations-which means for providing health care to me, the patient; handling billing and payment; and, taking care of other health care operations. Unless required by law, there will be no other uses and disclosures of this information without my authorization.
Pregnancy Waiver (X-rays): By my signature below, I am stating that to the best of my knowledge, I am not pregnant nor is pregnancy suspected at this time for the purpose of taking X-rays.
Self Pay: I understand that in the absence of health insurance coverage or in the instance of a denial of coverage by a third party provider that I will be held responsible for the services that I receive from Ride Balanced PLLC office.
Consent to Bill Insurance: I consent, if I am using a third party for payment of my service (health insurance, auto accident insurance, worker's compensation insurance, Parent/Guardian, etc.) to allow Ride Balanced PLLC (Dr. Bethanne Baretich) to submit all necessary information needed to receive payment for the services I received to these third parties. I further consent to accept assignment of payments from my insurance company to be paid directly to the office or doctor.
Video Material: I give the doctors and staff at Ride Balanced PLLC permission to video record/phonograph office visits and procedures for educational and/or office use.