APPLICATION FOR CARE AT Hanson Chiropractic Center

    I hereby authorize payment to be made directly to Hanson Chiropractic Center for all benefits which may be payable under a healthcare plan or from any other collateral sources. I authorize utilization of this application or copies thereof for the purpose of processing claims and effecting payments, and further acknowledge that this assignment of benefits does not in any way relieve me of payment liability and that I will remain financially responsible to [CLINIC NAME] for any and all services I receive at this office.



    Activities of Daily Life

    I have been advised that chiropractic care, like all forms of health care, holds certain risks. While the risk are most often very minimal, in rare cases, complications such as sprain/strain injuries, irritation of a disc condition, and although rare, minor fractures, and possible stroke, which occurs at a rate between one instance per one million to one per two million, have been associated with chiropractic adjustments.

    Treatment objectives as well as the risks associated with chiropractic adjustments and, all other procedures provided at the Hanson Chiropractic Center have been explained to me to my satisfaction and I have conveyed my understanding of both to the doctor. After careful consideration, I do hereby consent to treatment by any means, method, and or techniques, the doctor deems necessary to treat my condition at any time throughout the entire clinical course of my care.

    FEMALES ONLY:- please read carefully and check the boxes, include the appropriate date, then sign below if you understand and have no further questions, otherwise see our receptionist for further explanation.

    By my agree below I am acknowledging that the doctor and or a member of the staff has discussed with me the hazardous effects of ionization to an unborn child, and I have conveyed my understanding of the risks associated with exposure to x-rays. After careful consideration I therefore, do hereby consent to have the diagnostic x-ray examination the doctor has deemed necessary in my case.

    As a potential new patient, we feel it is important that you understand our office policies regarding, how patients of this practice are cared for, and the various methods we offer to facilitate payment for that care. Please read each policy carefully so there is no misunderstanding as to what you can expect as a patient of this practice, and what we expect in return.

    Over time it is our goal that you gain a greater understanding as to the purpose of chiropractic. Patients who are accepted for care have a unique opportunity to observe first hand the positive results and benefits derived from being under chiropractic care. This knowledge and awareness reaps a positive environment that promotes healing and encourages families to maintain good health. We want your experience with us to be an exceptional one, so help us to help you. Together, we can make affirmative changes in your life and the lives of those you care about.

    If you have any questions regarding these policies, before submitting your Application for Care, please ask and we will be happy to discuss them with you further. We want you to make an informed decision about your applying for care at this office. Therefore, it is important for you to understand these policies, how Dr. Ryan practices chiropractic, and how we can help you receive the best care to achieve your goals for health.

    Note: Patient and Office retains a copy of the is policy agreement.

    I hereby acknowledge receiving a copy of the practices ‘Office Policies’ a two page document. I assign to Hanson Chiropractic €enter the rights under all insurance and benefit plan documents, and authorize direct payment to each healthcare provider of all insurance and plan Gene/its payments for services provided to me (or the patient) by this provider. By paying my provider direct/y, my insurance company or employer is fulfilling its obligation to me (or the patient) under the health insuronce policy, or the employer is fulfilling its obligations as required by law. I also agree that I (or the patient) am financially responsible for charges not paid according to this assignment.
    by signature acknowledges that I have received a copy of these policies and understand this ‘Notice’. I further acknowledge that any concerns regarding these ‘Policies ’as well as all my questions have been answered by a qualified member of the Staff to my complete satisfaction.

    This office is required to notify you in writing, that by law, we must maintain the privacy and confidentiality of your Personal Health Information. In addition we must provide you with written notice concerning your rights to gain access to your health information, and the potential circumstances under which, by law, or as dictated by our office policy, we are permitted to disclose information about you to a third party without your authorization. Below is a brief summary of these circumstances. If you would like a more detailed explanation, one will be provided to you. In addition, you will find we have placed several copies in report folders labeled ’HIPAA’ on tables in the reception. Once you have read this notice, please sign the last page, and return only the signature page (page 2) to our front desk receptionist. Keep this page for your records.

    1. Treatment purposes- discussion with other health care providers involved in your care

    2. Inadvertent disclosures- open treating area mean open discussion. If you need to speak privately to the doctor, please let our start know so we can place you in a private consultation room.

    3. For payment purposes - to obtain payment from your insurance company or any other collateral source.

    4. For workers compensation purposes- to process a claim or aid in investigation

    5. Emergency- in the event of a medical emergency we may notify a family member

    6. For Public health and safety - in order to prevent or lessen a serious or eminent threat to the health or safety of a person or general public.

    7. To Government agencies or Law enforcement — to identify or locate a suspect, fugitive, material witness or missing person.

    8. For military, national security, prisoner and government benefits purposes.

    9. Deceased persons- discussion with coroners and medical examiners in the event of a patient’s death.

    10. Telephone calls or emails and appointment reminders -we may call your home and leave messages regarding a missed appointment or apprize you of changes in practice hours or upcoming events.

    11. Change of ownership- in the event this practice is sold, the new owners would have access to your PHI.

    1. To receive an accounting of disclosures

    2. To receive a paper copy of the comprehensive "Detail” Privacy Notice

    3. To request mailings to an address diherent than residence

    4. To request Restrictions on certain uses and disclosures and with whom we release information to, although we are not required to comply. If, however, we agree, the restriction will be in place until written notice of your intent to remove the restriction.

    5. To inspect your records and receive one copy of your records at no charge, with notice in advance

    6. To request amendments to information. However, like restrictions, we are not required to agree to them.

    7. To obtain one copy of your records at no charge, when timely notice is provided (72 hours). X-rays are original records and you are therefore not entitled to them. If you would like us to outsource them to an imaging center, to have copies made, we will be happy to accommodate you. However, you will be responsible for this cost.

    If you wish to make a formal complaint about how we handle your health information, please call Dr Ryan at (405) 341-0494. If he is unavailable, you may make an appointment with our receptionist to see him within 72 hours or 3 working days. If you are still not satisfied with the manner in which this office handles your complaint, you can submit a formal complaint to:

    DHHS, Office of Civil Rights
    200 Independence Ave. SW
    Room 509F HHH Building
    Washington DC 20201

    I have received a copy of Hanson Chiropractic’s Patient Privacy Notice. I understand my rights as well as the practices duty to protect my health information, and have conveyed my understanding of these rights and duties to the doctor. I further understand that this office reserves the right to amend this "Notice of Privacy Practice“ at a time in the future and will make the new provisions effective for all information that it maintains past and present.

    I am aware that a more comprehensive version of this “Notice" is available to me and several copies kept in the reception area. At this time, I do not have any questions regarding my rights or any of the information I have received.

    When a patient seeks chiropractic health care & we accept a patient for such care, it is essential for both to be working towards the same objective.

    Chiropractic has one primary goal. It is important that each patient understand both the objective & the method that will be used to attain it. This will prevent any confusion or disappointment:

    • Problem: Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column, which causes alteration of nerve faction & interference to the transmission of mental impulses, resulting in a lessening of the body’s innate ability to express its maximum health potential.

    • Solution: Adjustment: An adjustment is the specific application of forces to facilitate the body’s correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments on the spine.

    • Goal: Health: A state of optimal physical, mental & social well-being, not merely the absence of disease or infirmity.

    We do not offer to diagnose or treat any disease or condition other than vertebral subluxation.

    However, if during the course of a chiropractic spinal examination, we encounter non-chiropractic or unusual findings we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the service of a health care provider who specializes in that area. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others.

    OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body’s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations.

    All questions regarding the doctor’s objectives pertaining to my care in this office have been answered to my complete satisfaction.
    I therefore accept chiropractic care on this basis.