FINANCIAL & BILLING INFORMATION Certain services recommended by Dr. Naugle may not be considered medically necessary by your health plan. The fees for non-reimbursable services and/or supplies are your responsibility. All patients without health care coverage are liable for treatment rendered at the time of service unless payment arrangements are made prior to your appointment. Any default of your account turned over to collections is subject to a $50 collection fee that will be added to your total balance.I acknowledge and agree that if a part of my care is not covered, I will be financially responsible for this portion of my treatment. I have been made aware of the non-covered services and the costs prior to receiving the recommended services.I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and me. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment. There will be a $25 return check fee on all checks returned to the bank. NOTICE OF PRIVACY PRACTICES Better Life Chiropractic, Rehabilitation & Massage is required, by law, to maintain the privacy and confidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your health information.DISCLOSURE OF YOUR HEALTH CARE INFORMATION We may disclose your health information to: your insurance provider, medical consultations, state Workers Compensation, emergency services, for judicial and administrative proceedings, to law enforcement officials, coroners or medical examiners, and for public safety.YOUR HEALTH INFORMATION RIGHTS• You have the right to request restrictions on certain uses and disclosures of your health information. Please be advised, however, that Better Life Chiropractic, Rehabilitation & Massage is not required to agree to the restriction that you request.• You have the right to inspect and request a copy of your health information.• You have the right to request that Better Life Chiropractic, Rehabilitation & Massage amend your protected health information. Please be advised, however, that Better Life Chiropractic, Rehabilitation & Massage is not required to agree to amend your protected health information. If your request to amend your protected health information is denied, you will be provided with an explanation of our denial reason(s) and information about how you can disagree with the denial.• You have the right to receive an accounting of disclosures of your protected health information made by Better Life Chiropractic, Rehabilitation & Massage.• You have the right to receive a paper copy of the Notice if Privacy Practices at any time, upon request.I have read the Notice or Privacy Practices and understand my rights contained in the notice.CANCELLATION POLICYBetter Life Chiropractic, Rehabilitation & Massage requires a 24-hour cancellation notice for all massage appointments, and a 12-hour cancellation notice for all chiropractor appointments. Unless the cancellation is due to an emergency or approved by the doctors, a fee will be applied to your account, due upon your next appointment with your regular copay or coinsurance. The fees are: $35 if your appointment was with 1 provider (for example, you were scheduled for only a massage, or only with a doctor), and $45 if your appointment was with 2 providers (for example, you were scheduled for a massage and with a doctor). In the case of 3 missed appointments or habitual cancellations, not due to an emergency or work schedule, we will dismiss you as a patient and refer you to another clinic for your chiropractic needs. If you have any questions, please discuss them with the staff at the front office.CONSENT AND AGREEMENT Chiropractic examination and therapeutic procedures (including chiropractic manipulations, ultrasound, mechanical traction, heat and cold application, electrotherapy, and manual muscle therapy) are considered safe and effective methods of care. Occasionally, however, complications may arise. Any procedure intended to help may have complications. While the chances of experiencing complications are small, it is the practice of this clinic to inform our patients about them. These complications may include, but are not limited to, soreness, inflammation, soft tissue injury, dizziness, burns, and temporary worsening of symptoms. More serious complications are extremely rare. Additional information on the side effects and complications is available upon request. It is also our policy to inform you the procedure being performed and the risks and alternative treatments available. If your physician does not explain to your satisfaction, please ask for more information. I have read and understand the above statements regarding treatment side effects and I also understand that there is no guarantee of a specific cure or result.By signing below, you certify that you have read and understand our policies and agree to their terms and conditions.