Chiropractic Health Alternatives



Chiropractic Health Alternatives

558 Main Street

South Portland, ME 04106

Consent To Treatment Form

Professional healthcare providers are required to obtain your informed consent before starting treatment.

I __________________________(name), of_________________________(city, state) do hereby give my consent to the performance of conservative noninvasive treatment to the joints and soft tissues. I understand that the procedures may consist of manipulations/adjustments involving movement of the joints and soft tissues. These “adjustments” will be performed with the doctor using his hands, using a low force mechanical device called an Activator Instrument or an Impulse Device and/or using Sacro-Occipital Technique “Blocking” procedures. Physical therapy procedures and exercises may also be used in the treatment and rehabilitation process, including but not limited to electrical stimulation, ultrasound, low level laser therapy, myofascial release and stretching.

Although spinal manipulation/adjustment is considered to be one of the safest, most effective forms of therapy for musculoskeletal problems, I am aware that there are possible risks and complications associated with the procedures as follows:

Soreness: I am aware that like exercise it is common to experience muscle soreness in the first few treatments.

Dizziness: Temporary symptoms like dizziness and nausea can occur but are relatively rare.

Fractures/Joint Injury: I further understand that in isolated cases underlying physical defects, deformities, or pathologies like weak bones from osteoporosis may render the patient susceptible to injury. When osteoporosis, degenerative disk, or other abnormality is detected, this office will proceed with extra caution.

Physical Therapy Burns: Some of the therapies used in this office generate heat and may rarely cause a burn. Despite precautions, if a burn is obtained, there will be a temporary increase of pain and possible blistering. This should be reported to the doctor.

Stroke: Strokes happen with some frequency in our world, and there are some stories relating strokes with some types of chiropractic adjustments to the neck. Current research indicates that these strokes were already happening prior to the chiropractic treatment and were not caused by the chiropractic treatment. I am aware that nerve or brain damage including stroke is associated in this way with one in one million to one in ten million treatments. Once in a million is about the same chance as getting hit by lightening. Once in ten million is about the same chance as a normal dose of aspirin or Tylenol causing death. The methods for adjusting the neck used in this office do not involve twisting of the neck combined with a manipulative thrust, which in the claimed incidents, was purported to be contributory to the stroke.

Tests have been preformed on me to minimize the risk of any complication from treatment and I freely assume the risks.

Treatment Results

I also understand that there are beneficial effects associated with these treatment procedures including decreased pain, improved mobility and function, and reduced muscle spasm. However, I appreciate there is no certainty that I will achieve these benefits.

I realize that the practice of medicine, including chiropractic, is not an exact science and I acknowledge that no guarantee has been made to me regarding the outcome of these procedures.

Some services are identified as "investigational" or "unproven" in specific applications according to some insurance companies or other agencies. This means that the procedure has not yet been adequately investigated under the strict standards of research. This may be because it is too new, or that funding has not yet been found to support an appropriate research project. This particularly relates to Low Level Laser Therapy, also called "Cold Laser Therapy". If this type of therapy is used, I will be given a choice as to whether or not I would choose to have the therapy. It will be explained what the reason and the premise for using it are, and any other related facts will be discussed including any possible benefits and risks. Some insurance plans arbitrarily by their own standards as a means of limiting coverage deem some care "investigational" that is elsewhere established as valid. This is rare but if it happens, the decision will be challenged, but if the carrier is unbending, I may be responsible for payment of the denied service prior to this office knowing that it would be denied on this basis.

I agree to the performance of these procedures by my doctor and such other persons of the doctor’s choosing.

Alternative Treatments Available

Reasonable alternatives to these procedures have been explained to me including rest, home applications of therapy, prescription, or over-the-counter medications, exercises and possible surgery.

Medications: Medication can be used to reduce pain or inflammation. I am aware that long-term use or overuse of medication is always a cause for concern. Drugs may mask pathology, produce inadequate or short-term relief, undesirable side-effects, physical or psychological dependence, and may have to be continued indefinitely. Some medications may involve serious risks.

Rest/Exercise: It has been explained to me that simple rest is not likely to reverse pathology, although it may temporarily reduce inflammation and pain. The same is true with ice, heat, or other home therapy. Prolonged bedrest contributes to weakened bones, loss of muscle tone and joint stiffness. Exercises are of limited value but are not corrective of injured nerve and joint tissues, and can lead to compensatory and degenerative changes if performed on compromised joints.

Surgery: Surgery may be necessary for joint stability, tendon or ligament tears or serious disk rupture. Surgical risks may include unsuccessful outcome, complications, pain, reaction to anesthesia, and prolonged recovery.

Non-treatment: I understand the potential risks of refusing or neglecting care may include increased pain, scar/adhesion formation, restricted motion, possible nerve damage, increased inflammation, and worsening pathology. The aforementioned may complicate treatment making future recovery and rehabilitation more difficult and lengthy.

Non-Compliance with Treatment Plan

When a treatment plan is begun, I understand that following through with the treatment prescribed is essential for the best outcome possible. This includes keeping my appointment times and following directions in regard to doing or not doing activities, getting rest and other instructions that may be given.

Financial Responsibility and Insurance Limitations

Treatment will be recommended and provided in the best way and frequency determined to give me the most benefit. Care plans are determined by what is needed in the effort to restore balance and function as much as is reasonably possible. I will be expected to pay for my deductible, copayment, co-insurance or for non-covered services or items at the time of service, unless an agreement to do otherwise has been established before the services are provided. I will be notified prior to receiving any treatment or product that is not covered by insurance and I accept that it will be my responsibility to pay for these services or items if I choose to receive them.

Many insurance policies have limitations of how many services or limits of what they will pay for. Some services may be applied to my deductible. Because there are so many different plans even from the same insurance carrier, it is not possible for this office to determine what my coverage is, how much of my deductible or coverage limits I have met in other facilities or with other providers. Therefore it is my responsibility to understand my own insurance plan coverage and I will be responsible for any deductibles, copayments and care beyond the limits of my policy coverage.

Even though this office submits insurance claims on a weekly basis, there is a delay between the service date and getting notice back from the insurance about what they will or will not cover, so I may have received more care after my coverage limits have been exceeded without this office or me knowing that. Most times an explanation of what has been paid or denied is sent by mail or is electronically available to me, the patient, before it gets to this office, so I will monitor these to make sure I understand what my insurance has covered and what it will cover going forward. If something is an unexpected shift to my responsibility by my insurance carrier on the explanation of benefits that is sent to this office, I will be notified as soon as possible if I have a balance owing on my account and prior to proceeding with care, that further care will be my responsibility. If I have any questions about notifications I receive directly from my insurance carrier I can contact them directly or bring the correspondence to this office to help get an explanation.

Every effort will be made to provide cost-effective care aimed towards assisting me with my health concerns. There is no implied or other guarantee that the work will accomplish any of all of the goals. If progress is not being made, care will be reassessed and other options considered including changing the treatment plan or methods, referral to other providers to co-treat the condition and/or discontinuation of care at this office. Payment for services is for the service and is not payment for a result.

Consent to Care and the above Policies

As well as having been given time to read this consent form, I have opportunity to review it on-line through the website for Chiropractic Health Alternatives (Chiro-Health-) at any future time. The doctor will also give me opportunity to verify this with verbal consent before he proceeds with care. I also am welcome to ask the doctor for explanation of any procedure about to be performed during the course of all future treatment. If at any time I choose to withdraw consent for any procedure to be performed in the future, I can do so by stating that to the doctor and will then be asked to write a statement to that effect and sign and date it. Without doing so, the stated consent from this form will be implied with all future care utilizing the same or significantly similar services.

I have read or had read to me the above explanation of chiropractic treatment and other policies related to the care that will be provided. Any questions I have had regarding these procedures have been answered to my satisfaction. I have made my decision voluntarily and freely.

To attest to my consent to these procedures, I hereby affix my signature to the authorization of treatment.

____________________________________ ____________________

Signature of Patient Date and Time

____________________________________

Signature of Witness

FOR THE DOCTOR TO COMPLETE

Patient Status At Time of Informed Consent Process

Based on my personal observations, medical history, and direct conversation with the patient, __________________________, I conclude that throughout the consent process the patient was:

____ Of Legal Age

____ Oriented x 3

____ Disoriented as to

____ Coherent and Lucid

____ On prescription/OTC medication but unimpaired

____ Proficient in understand the English language

____ Assisted in understanding by an interpreter

Interpreter’s name:_____________________________________

____Resolute in denying the use of alcohol and or recreational drug use prior to consent

____Unable to give legal consent

____ Consent give through legal guardian

Name______________________________ Relationship___________________

Patient’s questions (if any) and information supplied are as follows:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Comments:______________________________________________________________________________________________________________________________________________________________________________________________________________________________

I certify that the above accurately describes the above named patient’s status during the informed consent process on __________________.

__________________________

Signature of Doctor

__________________________

Date

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