Dr. Nelson Santos


Dr. Nelson Santos, D.C.

Connect With Us:

Email: drnelsonsantosdc@gmail.com

Call Us: (310) 621-8224

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Forms

Dr. Nelson or his office personnel will inform you which form(s) to fill out.
Each form below can be filled out and submitted one by one as needed.

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:

  1. While rare; some patients may experience short term aggravation of symptoms including soreness, muscle tightness, and ligamentous pain.
  2. 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.
  3. 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.

Signature:

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.

I wish to be contacted in the following manner ( check all that apply):


  O.K. to leage message with detailed information
  Leave message with call-back number only

  O.K. to mail to my home address
  O.K. to mail to my work/ofice address
  O.K. to fax to this number

  O.K. to leave message with detailed information
  Leave message with call-back number only



The Privacy Rule generally requires healthcare providers to take·reasonable steps to limit the use or disclosure of, and requests for PHI to the minimum necessary to accomplish the intended purpose. These provisions do not apply to uses or disclosures made pursuant to an authorization request~ by the individual.

Healthcare entities must keep records of PHI disclosures. Information provided.below, if completed property, will constitute an accurate record.

Note: Uses and disclosures for TPO may be permitted without prior consent in an emergency.

Record of Disclosures of Protected Health Information:

(1) Check this bax if the disclosure is authorized
(2) Type key: T=Treatment Records; P=Payment Information; O=Healthcare Operations
(3) Enter how disclosure was made: F=Fax; P=Phone; E=Email; O=Other


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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:

  1. 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
  2. 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
  3. 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.

Signature:

Dated the day of ,

INITIAL HEALTH STATUS





0-No Pain 10-Unbearable Pain

Occasional Constant

0-No Interference 10-Unable to carry on any activities

Excellent Poor


I certify to the best of my knowledge, the above information is complete and accurate. If the health plan information is not accurate, or if I am not eligibie to receive a-health care benefit through this provider, I understand that I am liable for all charges for services rendered and I agree to notify this doctor immediately whenever I have changes in my health condition or plan coverage in the future. I understand that my chiropractor may need to contact my physician if my condition needs to be co-managed. Therefore I give authorization to my chiropractor to contact my physician, if necessary.

Signature:

PATIENT INFORMATION FORM






I understand that this is a quotation of benefits and is NOT a guarantee of payment, and the agreement is between the Insurance Carrier and me. I authorize any and all payment from my insurante carrier directly to this office with the understanding that all monies be credited to my account upon receipt. Any denial of payment becomes my responsibility (patient).

Credit card information: Please do not provide a credit card number with this online form, as it is not secure. Instead, please call us at (310) 621-8224 to provide it to our office personnel. You may also provide it when arriving at our office.

Signature:

PRC takes pride in the quality of care we offer our patients. In order to do this we have a strict cancellation policy. Please read and enter your name as signature below. PRC requires a 24-hour cancellation notice prior to your appointment time. If sufficient notice is not given, a fee of $35 will be charge to the credit card we-have on file.