Acknowledgment of Clinic Terms

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Acknowledgment of Clinic Terms Our GOAL The goal of CHIRO-FIT, Inc. is to detect and correct subluxations of the spine and body. We do not focus on the treatment of pain and disease, instead aim to help relieve the body of any nerve interference that may be inhibiting the body from functioning properly. When interference is removed from a nerve, you provide the body with an increased ability to create healthier cells and therefore a healthier you. We do this by evaluating for misaligned bones in the spine called vertebral subluxations and delivering an adjustment to those areas of the spine or affected joints located in the extremities of the body. What we DO We do at CHIRO-FIT, Inc. offer affordable and accessible chiropractic adjustments to the public with the intent to help remove nerve interference of the body. We do use our hands to apply a specific and controlled thrust to the targeted joint in the spine (vertebral subluxation) and extremities of the body by our licensed doctor of chiropractic. The applied force to the joint is termed as an adjustment or manual manipulation We do offer roller table massage, hydromassage and mechanical massage to help decrease muscle tightness and connective tissue adhesions. This is to help in creating easier adjustments that last for longer periods. What we DON T - (Limitation of Services) We do not treat pain or disease. We only provide preventive routine care (wellness) by way of chiropractic adjustments, correcting spinal misalignments (vertebral subluxations) with a goal of removing any possible nervous system interference. We do not accept, bill, prepare, respond or submit documentation to any third-party insurance, Medicare or health insurance companies for payment. You may choose to submit receipts to your insurance company or other third-party health care programs however, payment/reimbursement for such services by insurance companies is neither implied nor agreed to by this office. We take no responsibility for non-payment by insurance companies, Medicare for services rendered at our office. Upon patients written request we will provide the patient and/or legal guardian/authority with a copy of their treatment records (fees may apply). We do not have: x-ray, extensive diagnostic equipment, e-stim, ultrasound, laser therapy in our clinics. We do not treat, prepare or submit reports for any motor vehicle accident, personal or work related injuries. If I am involved in such event, it is my responsibility to notify the chiropractor and seek care with a medical doctor or other healthcare provider who can treat your newly acquired conditions or injuries. FINANCIAL OBLIGATION Patient acknowledges that all payments for services will be paid immediately following services rendered. In the event a check for service payment is returned there will be an additional $30 fee applied to the existing owed amount to the patient. Initial exam, consultations fees will be paid for at time of completion. In event that the doctor feels imaging (x-ray, etc.) are necessary prior to providing any care a referral may be made however, it is the patients responsibility to identify cost obligation with the providing imaging and/or personal insurance company prior to receiving any imaging. CHIRO-FIT, Inc. will not accept payments on behalf of any other providing clinics/insurance companies. CHIRO-FIT, Inc. and/or the providing clinic doctor reserves the right to deny services to anyone for any reason, or if the doctor feels that the patient's health is not being best served within our clinic. Our patient s health & well-being is our number one interest. Again, we do not accept, bill, prepare, respond or submit documentation to any third-party insurance, Medicare, Medicaid or health insurance companies for payment. You may choose to submit receipts to your insurance company or other third-party health care programs however, payment/reimbursement for such services by insurance companies is neither implied nor

agreed to by this office. We take no responsibility for non-payment by insurance companies and/or Medicare for services rendered at our office. All owed fees must be paid prior to receiving any future care. I, (Patient Printed Name) have read, fully understand and consent to all of the above statements. All questions regarding the clinic policies and care provided at CHIRO-FIT, Inc. have been answered to my complete satisfaction. I therefore accept all chiropractic services rendered to me at this location. (Patient Signature) (Date) CONSENT TO EVALUATE AND/OR TREAT A MINOR (To be completed by parent/legal guardian) I, (Parent/Legal guardian) of (Patients Name) consent and give my permission for my child to receive chiropractic care/services by CHIRO-FIT, Inc. at this location. Witness:

INFORMED CONSENT Please read this information carefully and ask Dr. Boston if there is anything that you do not understand. The nature of chiropractic treatment: The doctors will use his/her hands or a mechanical device in order to move your joints. You may feel a "click" or "pop", such as the noise when a knuckle is "cracked", and you may feel movement of the joint. Hydromassage, mechanical massage, roller table massage, topical analgesics are also services provided in clinic. Possible Risks: As with any health care procedure, complications are possible following a chiropractic manipulation. Complications could include fractures of bone, muscular strain, ligamentous sprain, dislocations of joints, or injury to intervertebral discs, nerves or spinal cord. Cerebrovascular injury or stroke could occur upon severe injury to arteries of the neck. A minority of patients may notice stiffness or soreness after the first few days of treatment. Irritation, bruising, soreness could also be associated with the additional massage & topical analgesics. Probability of risks occurring: The risks of complications due to chiropractic treatment have been described as "rare", about as often as complications are seen from the taking of a single aspirin tablet. The risk of cerebrovascular injury or stroke, has been estimated at one in one million to one in twenty million, and can be even further reduced by screening procedures. Chiropractic treatment: has been shown to be effective in the treatment of neck and back conditions such as pain, numbness, muscle spasm, decreased mobility, headaches etc. Routine chiropractic treatment can result in better function, improved joint motion, improved overall health and an increased active lifestyle. Alternatives to chiropractic wellness care are resources listed (but not limited to): Physical Therapy, Medical Doctors, Orthopedic Doctors, Surgeons. I have read the explanation above and I have had the opportunity to have any questions answered to my satisfaction. I have fully evaluated the risks and benefits of undergoing treatment. I consent to the chiropractic treatments offered or recommended to me by the treating doctor(s) of CHIRO-FIT, Inc. Patient Printed Name: Patient or Legal Guardian Signature: Date: Witness of Signature: Date:

Advanced Beneficiary Notice of NonCoverage (ABN) MEDICARE ELGIBLE PATIENTS Notifier: CHIRO-FIT, Inc 520 SW 3 rd St. Ste 1B Ankeny, Iowa 50023 PRINTED PATIENT NAME: NOTE: If Medicare doesn t pay for maintenance chiropractic care below, you may have to pay. Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the maintenance chiropractic care below. MAINTENANCE CHIROPRACTIC CARE REASON MEDICARE MAY NOT PAY: Chiropractic Adjustments for the purpose of maintenance care is not payable service by Medicare. Estimated Cost per Visit: $15 - $40 WHAT YOU NEED TO DO NOW: o Read this notice, so you can make an informed decision about your care. o Ask us any questions that you may have after you finish reading. o Choose an option below about whether to receive the maintenance chiropractic care listed above. Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this. Additional Information: This ABN form is only good for up to one (1) year. OPTIONS Check only one box. We cannot choose an option for you Option 1: I want the chiropractic maintenance care listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles. By selecting this option we will refer you to another provider. Option 2: I want the chiropractic maintenance care listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed. Option 3: I don t want the chiropractic maintenance care listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay. By selecting this option we will refer you to another provider. This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800- MEDICARE (1-800-633-4227/TTY: 1-877-486-2048). Signing below means that you have received and understand this notice. You also receive a copy. PATIENT/LEGAL GUARDIAN SIGNATURE: DATE: CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call: 1-800-MEDICARE or email: AltFormatRequest@cms.hhs.gov. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

Today s Date: First Name: Date of Birth: Height: Last Name: Age: Weight: Home Address City State Zip Phone Number: Email: Communication Preference (circle one): Phone or Email Employer Employer Address: Emergency Contact: Emergency Contact Phone Number: Are you Medicare Eligible? (circle one) Yes or No Do you have a Health Savings Account (HSA) or Flexible Spending Account (FSA)? Yes or No If you had to pick one health problem we could help with, what would it be? When did the problem start? How did it start? Have these problems ever happened before? Is it worse in morning or night? How often do you feel the pain? How long does the pain last? Have you seen any other doctors for this problem? Please list all surgeries and the year you received them: Have you been in any previous automobile or experienced workplace, personal injuries? Did you receive treatment due to the injury? Yes or No

Do you ever experience any dizziness? Yes or No Have you ever seen a chiropractor before? Yes or No If yes, who/where was the chiropractor you seen? In the last year, have you received any x-rays of your spine? Yes or No If yes: Why did you receive them? Where did you receive them? Do you or a family member have a history of Arthritis? Yes or No What are your normal hobbies/activities you partake in? How often do you go to the gym? What activities or hobbies have you been unable to do because of your problem? TO BE COMPLETED BY PATIENT: Patient Printed Name: Date: LEGAL GUARDIAN SIGNATURE (IF MINOR):

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