Aurora Chiropractic Financial Policy & HIPAA
Financial Policy
Beginning in 2018 we will be initiating an updated financial policy. In order to receive care at the clinic you must agree to terms with this policy. Below are the two options available to choose from:
1. If you want your services submitted to insurance, you must have a current debit, credit, HSA, or FSA card number on file prior to treatment.
2. If you do not want a credit card number on file, you will be expected to, and must pay, for your services the same day of treatment using cash, credit card, debit card, HSA card, FSA card, or check.

The guidelines of the financial policy are as follows:
 *Credit cards will only be run if the account has become past due (greater than 90 days after claim(s) have been processed). Patients will be notified before any card will be charged for past due bills*
 If you need to make payments on a bill over $100, we will setup a monthly payment plan not to exceed 3 months.
 Accounts must be less than $100 if you are under active care (currently coming in for treatment).
 You will have the choice to have your card run on the 1st or the 15th of the month.
 If your card declines, we will contact you for updated, accurate information to settle your account prior to further care.
 If you cannot be contacted or give us false information, you will be turned over to our collection agency immediately and accounts will have to be paid in full before further care.
 We can run your card to pay your bill prior to 90 days if you choose to do so below.
 Children/dependents can also be under the same card information as the patient to cover families.
 Completed forms will be secured so no information will be released outside of the office for any means.

When it comes to statements and billings we reserve the right to mail and/or email them to the email we have on file.

*Minors/Dependents*
We cannot legally administer care to any persons under the age of 18 without a parent or guardian accompanying them to the office for their initial visit. Care will be refused unless a parent or a guardian accompany the minor/dependent to their initial visit and the new patient paperwork, informed consent, permission to treat a minor, HIPAA release and this form are on file. There are absolutely no exceptions to this law. Please plan accordingly to accompany your child/dependent to their initial appointment.

The federal laws that protect your protected health information (“HIPAA”) do not provide you with complete privacy. HIPAA allows your health care provider to use or disclose your protected health care information without further authorization or consent from you in a number of circumstances, such as:
• In the course of providing you treatment;
• In the event a referral to another health care provider if/as necessary for the diagnosis, assessment, or treatment of your health condition;
• For insurance and billing purposes;
• For internal clinic purposes (related to quality control or operations); and
• In limited and unusual circumstances related to public health matters and research.

Our privacy policy. We are very concerned with protecting your privacy, and always will respect the privacy of your health information. Along with this consent form, you will be given a copy of our privacy policy, in detail. You have the right to review our privacy policy before you sign this consent form. We reserve the right to change our privacy policy. If we make a change, we will notify you in writing when you come in for treatment or by mail.

Your right to limit uses or disclosures. You have the right to restrict our ability to use or disclose your protected health information with specific individuals, companies, or organizations. If you would like to place any restrictions on the use or disclosure of your health information, you must inform us in writing.

Your right to authorize us to disclose your protected health information. You have the right to authorize us to disclose your protected health information to specific individuals, companies, or organizations. If you would like to make an authorization, we will ask you to complete an authorization form.

Your right to revoke any limitation, authorization, or consent. You have the right to revoke any limitation or authorization to use or disclose your protected health information at any time. Your revocation must be in writing. If you refuse to give us an authorization or consent or revoke any authorization or consent in the future, it will not affect the treatment we provide to you or the methods we use to obtain reimbursement for your care.

I ACKNOWLEDGE receipt of the PRIVACY POLICY and CONSENT to my personal health information being used in the manner described above. I am also acknowledging that I have received a copy of this consent.

Email address *
First and Last Name *
Your answer
Upon arrival at the office please be prepared to provide your credit card to be kept on file *
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