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Old Bridge Spine - New Patient Case History
















I understand and agree that health and accident insurance policies are an arrangement between the insurance carrier and myself. Furthermore, I understand the office will prepare any necessary reports and claims to assist me in making collection from the insurance company and that any amount unauthorized to be paid directly to the office will be credited to my account on receipt. However, I clearly understand and agree that all services rendered are charged directly to me and that I am personally responsible for payment. I also understand that I’ll suspend or terminate any case and treatment any less for professional services rendered me will be immediately due and payable.


I irrevocably assign to Old Bridge Spine

Dear Patient, This is to remind you that the office will be reinforcing our 24 hour cancellation and missed appointment fee policy. If you must cancel your scheduled appointment it must be done prior to 24 hours. Otherwise a fee of $25 will be charged. Last minute cancellations and missed appointments cause significant scheduling conflicts with other patients who prefer those scheduled times. We appreciate your cooperation in this matter. Thank you. Sincerely, Old Bridge Spine


This notice describes how medical information about you may be used and disclosed and how you can get access to this information: Please review it carefully.

This notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment, or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. Protected health information is information about you, including demographics, that may identify you and that relates to your past, present and future physical or medical health or conditions and related to health care services.

We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices by calling the office and requesting that a revised copy be sent to you in the mail or asking one at the time of your next appointment.

Uses and Disclosures of Protected Health Information:

Uses and disclosures of Protected Health Information Based upon Your Written Consent:

You will be asked by your chiropractor/physical therapist/acupuncturist to sign consent form(s). Once you have consented to use and disclosure your protected health information for treatment, payment of health care operations by signing the consent form, your chiropractor/physical therapist/acupuncturist will use or disclosure your protected health information as described in this section. Your protected health information may be used and disclosed by your chiropractor/physical therapist/acupuncturist, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of the physician’s office.

Healthcare Operations:

We may use of disclose, as needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality of assessment activities, employee review activities, training of medical students, licensing, marketing and fundraising activities, and conducting or arranging for other business activities. For example, we may disclosure your protected health information to chiropractor/physical

We may use or disclosure your protected information as necessary, to provide you with information about your treatment alternatives or other health related benefits and services that may be of interest to you. We may also use and disclose your protected health information for chiropractor/physical therapist/acupuncturist marketing activities. For example, your name and address may be used to send you a newsletter about our practice and the service you offer. We may also send information about products or services that we believe may be beneficial to you. You may contact our office to request that these materials not be sent to you. We may use or disclose your demographic information and the dates that you received treatment from your chiropractor/physical therapist/acupuncturist, as necessary, in order to contact you for fundraising activities supported by our office. If you do not want to receive these material, please contact our office an request that these fund raising materials not be sent to you.

Following are some types of use and disclosures of your protected health care information that the office is permitted to make once you have signed consent forms.

Treatment, Payment, Healthcare Operations, Others Involved in your Healthcare, Emergencies, Communication Barriers:

Other permitted and required uses and disclosures that may be without your consent, authorization or opportunity to object, we may use or disclose your protected health information in the following situations without your consent or authorization includes:

Required by Law, Public Health, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration, Legal Proceedings, Law Enforcement, Coroners, Funeral Directors, Organ Donations, Research, Criminal Activity, Military Activity, National Security, Worker’s Compensation and Inmates

Required use and disclosures under the law, we must make disclosures to you and when required by the secretary of Department of Health and Human Services to investigate or determine our compliance with the requirement of Section 164.500 et. Seq.

Your Rights:

You have the right to inspect and copy your protected health information. This means you inspect and obtain a copy of your protected health information about you that is contained in a designed record set for as long as we maintain the protected health information. A “designed record set” contains medical and billing records and any other records that your chiropractor/physical therapist/acupuncturist and the practice uses for making decisions about you.

Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, of use in, civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have this decision reviewed. Please contact our office if you have any questions about access to your medical records.

You have the right to request a restriction of your health information. You have the right to request to receive confidential communication from us by alternative means or at an alternative location. You may have the right to have your chiropractor/physical therapist/acupuncturist amend your protected health information. You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. You have the right to obtain a paper copy of this notice form from us upon request. You have the right to complain to use or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with use by notifying our office of your complaint. We will not retaliate against you for filing a complaint.


I understand that as a part of my healthcare, this organization originates and maintains records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:

A basis for planning my care and treatment

I understand and have been provided with a Notice of Information Practices that provides a more complete description of information and disclosures. I understand that I have the right to review the notice prior to signing this consent. I understand that the organization reserves the right to change their notice and practices and prior to implementation will mail a copy of any revised notice to the address I’ve provided. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry our treatment, payment, or healthcare operations and that the organization is not required to agree to the restriction requested. I understand that I may revoke this consent in writing, expect to the extent that the organization has already take action in reliance theron. I request the following restrictions to the use of disclosure of any health information.


Patient, please discuss any questions or concerns with the Chiropractor, Physical Therapist or Acupuncturist before signing this consent.

I hereby irrevocably request and consent through the appropriate personnel, to furnish medical care and treatment to me, or the patient named below, considered necessary and proper diagnosing or treating my physical condition. I consent to the performance of chiropractic adjustments/procedures, physical therapy procedures and acupuncture procedures.

I have had the opportunity to discuss with the doctor and/or other clinical staff personnel the benefits of the procedures and other treatments outlined below. Alternatives to treatment have been reviewed.

Chiropractic Care: Though chiropractic adjustments and treatments are usually beneficial and seldom cause any problem, I understand and am fully informed that there are some risks to treatment. Risks include, but are not limited to, fractures, disc injuries, strokes, dislocations, and sprains.

I understand that chiropractic/physical therapy/acupuncture is not an exact science and that, therefore, reputable practitioners cannot fully guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the chiropractic/physical therapy/acupuncture treatment that I have requested and authorized. I have had the opportunity to read this form and ask questions. My questions have been answered to my satisfaction. I irrevocably consent to the proposed treatment.

All Patients: The following OFFICE POLICY applies

You the patient are financially responsible for any procedures, treatments, supplies and or office visits by this office to you and your case.

In the event of accepting your insurance on assignment, we have to wait for payment; this courtesy may be withdrawn if any circumstances warrant it.

We will bill your insurance company on a 30 day cycle as long as you are receiving chiropractic, physical therapy or acupuncture treatment in this office.

You are required to sign an “Authorization to Pay Physician/Clinician” form and any other assignment documents required by your insurance company on your first visit.

Our office does NOT guarantee that your insurance will pay. We will make every attempt at the beginning of your health care to receive verification of your policy and what it covers. However, if for some reason your insurance claims are denied, you are responsible for the full amount of the bill.

Your insurance should pay within 30 days. If your insurance has not paid within 60 days, you must pay the balance due and be reimbursed by your insurance company.


I hereby authorize OLD BRIDGE SPINE

A copy of my Summary Plan Description (SPD) and a description of the Plan’s Claim Appeal Procedure for the subject period, as well as all medical and financial information contain in my insurance file, including but not limited to treatment for venereal disease, alcoholism and drug abuse, abortion, mental disorder, and HIV status relating to my examination, treatment and hospital confinement in connection with the determination which is being appealed.

I understand this information is privileged and confidential and will only be released as specified in this Authorization, or as required or permitted by law. This authorization is valid for a period of six years unless otherwise limited by the plan or by the governing%2

Should your insurance company request written re

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