Nelson Santos, D.C., A.R.T.
2940 Westwood Blvd. Suite 5
Los Angeles, California 90064
(310) 621-8224 (323) 576-S607 Fax
INFORMED CONSENT TO CHIROPRACTIC TREATMENT
Doctors of Chiropractic who use manual therapy techniques are required to advise patients that there are risks associated with such treatment. In particular you should note:
While rare; some patients may experience short term aggravation of symptoms including soreness, muscle tightness, and ligamentous pain.
There are reported cases of stroke associated with common neck movements including rotation manipulation of the upper cervical spine. Present medical and scientific evidence does not establish a definite cause and effect relationship between the cervical spine manipulation and the occurrence of stroke. There are reported rates of showing 1 in 1 million will experience stroke. However, you are being informed of the possibility regardless of the extreme remote chance.
There are reported cases of strain/sprain injuries of ligament and muscle as well. Again this is rare and the techniques utilized by the above doctors reduce the risk even more.
Chiropractic treatment, including manipulation, has been subject of government reports and multi-disciplinary studies, and bas been to be safe and effective care option for the treatment of back and neck pain as well as headaches. Other conditions involving radiating pain, numbness, muscle spasm, loss of mobility and other have also shown improvement.
I acknowledge I have had the opportunity to discuss the associated risks as well as the associated risks as the nature and purpose of treatment with my chiropractor.
I consent to the treatments offered or recommended to me by my chiropractor or referring physician, including spinal manipulation, Active Release Technique, corrective exercises, various modalities of physiotherapy and diagnostic x-rays. I intend this consent to apply to all my present and future care.
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PATIENT RECORD OF DISCLOSURES
In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual's office instead of the individual's home.
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Nelson Santos, D.C., A.R.T.
2940 Westwood Blvd. Suite 5
Los Angeles, California 90064
(310) 621-8224 (323) 576-S607 Fax
GROUP HEALTH INSURANCE ACKNOWLEDGMENT AND UNDERSTANDING
I hereby acknowledge that I am receiving (or about to receive) health care services
at the office of Dr. Nelson Santos I have been advised that the doctor(s) providing
the services is (are) willing to bill my group health insurance for these services,
provided that there continues to be a reasonable chance that payment will be made
by insurance proceeds.
I understand that if it is determined either:
That if my company refuses to acknowledge, or denies a claim based on
medical necessity, deductible not having been met, co-insurance, co-pay,
termination, maxed benefits, coverage limitation of benefits, or
If my insurance company denies a claim due to my negligence in responding
to any xquestionnaire or information requested ofme or any member on my
health plan, or
If partial payment is made by my insurance company for some services, or
disallows services provided, such as A.& T., therapies, massage, orthotics, xrays,
cervical pillows, supplements, etc. because there items are not covered,
or are only partially covered, under my policy,
then I agree to make payment and accept financial responsibility for all services
rendered to myself or any member on my health plan.
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INITIAL HEALTH STATUS
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PATIENT INFORMATION FORM
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