Please fill out the Pediatric Health History Intake Form

Patient Information

Does your child have any problems with the following? Please check all that apply:

Parent/Guardian Information

Chief Complaints

Secondary Complaint

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FRONT of the Body:

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Assignment of Benefits, Financial Policy & Billing Practices

Services provided by Chiropractic Solutions of Georgia, LLC., dba Douglas Family Chiropractic. are payable at the time services are rendered. This includes any deductible, coinsurance, copayment, non-covered services, or uninsured patients. We accept the following forms of payment:  Cash, Check, Debit, Credit, and most Health Savings Account (HSA) Card Flexible Spending (FSA) Card.  **All NSF checks will be assessed with a $35 fee.

I hereby authorize my insurance company to make payments to Chiropractic Solutions of Georgia, LLC., dba Douglas Family Chiropractic for chiropractic or massage services rendered to me or my dependents, if applicable. Should my insurance carrier deny Chiropractic Solutions of Georgia, LLC., dba Douglas Family Chiropractic payment, I understand that I am financially responsible for all charges. I authorize Chiropractic Solutions of Georgia, LLC., dba Douglas Family Chiropractic to release any and all of my records to my insurer, or any third party payer, legally responsible for the payment of chiropractic or massage. I certify that the information provided or to be provided by me is correct and complete to the best of my knowledge. It is my responsibility to update any and all personal, insurance, and health information. I agree that a photocopy of this assignment shall serve in lieu of the original.

Your insurance policy is a contract between you, your employer, and the insurance carrier. We are not a party in that contract. We will file a claim with your insurance carrier for our contracted plans. If you have a dispute regarding a deductible, coinsurance, copayment, covered/non-covered services, or the allowed amount by your insurance carrier, you have to contact them directly. We will assist you if we can. Insurance is billed as a courtesy for our patients with the following insurance companies: *If your carrier is not listed, inquire within. 

Aetna Active Healthcare Alliant Ambetter Cigna Humana

Kaiser Medicare Optum United Healthcare Blue Cross Blue Shield

Please note that the patient's responsible for knowing, verifying, and understanding their insurance benefits. In certain circumstances or at the patient's request, Chiropractic Solutions of Georgia, LLC., dba Douglas Family Chiropractic may verify benefits, but quotes never guarantee coverage. All denied charges are your responsibility if your insurance carrier does not pay. Not all services rendered are covered benefits. We will do our best to verify which services and how many are covered and any deductible, coinsurance, or copayment you may have. Your carrier can change at any time without any notification to us. It is your responsibility to notify us of any change or termination of your policy. If there is a dispute between the patient and the insurance company at any time, the balance will be the patient's sole responsibility. 

If an insurance payment results in an overpayment on your account, this will automatically be credited to the next visit. If you wish to request a refund, please email [email protected]. Refunds can take up to thirty (30) days to process and are issued via check only. 

Payment plan options are available under certain circumstances and available in various terms. Medical treatments cannot be discounted. Therefore, a discounted care plan is created by providing free visits at the end of a care plan. In the event you do not complete your care plan, the care you received will be recalculated using the listed fee schedule. Any payment(s) you have made above the cost of care you received will be refunded. Refunds can take up to thirty (30) days to process and are issued via check only. 

CareCredit is a health and wellness credit card with flexible financing options to pay for care you want or need over time. This credit card requires a credit check and approval to take advantage of its financing options. In the event you do not complete your care plan and submit a written request for a refund, the care you received will be recalculated using the listed fee schedule. Any payment(s) you have made above the cost of care you received will be refunded minus a 15% recovery fee and a $55 administrative fee. Refunds can take up to thirty (30) days to process.  

We understand that temporary financial issues may arise. We do not want this to affect your care or the reason you cancel appointments. Don't hesitate to contact the Office Manager so that a payment arrangement can be made. We prefer to work with our patients as much as possible; however, any delinquent account balances will be forwarded to our collection agency. The attorney and/or collection agency will assess balances transferred to our collection agency as additional fees. Accounts are considered delinquent after 120 days from the date of service.

Self-pay patients are required to have a waiver on file and pay at the time of service. Self-pay patients are required to keep a card on file at all times to schedule. The card on file will be charged after the patient's visit.

I request that authorized insurance benefits be paid to Chiropractic Solutions of Georgia, LLC., dba Douglas Family Chiropractic, for any covered services furnished by Chiropractic Solutions of Georgia, LLC., dba Douglas Family Chiropractic. I agree to pay Chiropractic Solutions of Georgia, LLC., dba Douglas Family Chiropractic, for all deductibles, co-pays, and/or coinsurances on my claim. I have read and understand the above policies.

No-Show/Cancellation Policy

Our mission is to provide high-quality, practice-member-centered care that addresses root causes and allows practice members to thrive. Due to our high volume of practice members and the desire to accommodate both our members and providers, we ask that you give the office 24 business hours' notice before canceling or rescheduling your appointments.

 A No-Show or cancellation with less than 24 hours notice significantly limits our ability to make the appointment available for another patient in need.

To remain consistent with our mission, we have instituted the following policy:

1. Please give our office 24 hours notice if you need to reschedule your appointment. This will allow us to provide care to another Practice Member.

2. A "No-Show," "No-Call," or missed appointment without proper 24-hour notification will be assessed a $50 fee. 

3. This fee is not billable to your insurance.

4.  If you are 15 or more minutes late for your appointment, the appointment may be canceled and rescheduled.

5. As a courtesy, we send reminder texts for appointments in advance. Please note that the cancellation policy remains in effect if a reminder call or message is not received.

6. More than three missed appointments may result in termination of care.

If you have any questions regarding this policy, please let our staff know; we will gladly clarify them.

Patient Rights & Responsibilities

You, our patient, have the right to:

• Be afforded considerate and respectful care in a safe environment and free from mental, physical, sexual, and verbal abuse, neglect, and exploitation.

• Medical care without discrimination regarding race, religion, national origin, sex or sexual orientation, disability, payment source, or age.

• Be fully informed, in lay terms, concerning your health, diagnosis, treatment options, and prognosis. You have the right to helpful information and answers to your questions.

• Make decisions about your care and include or exclude family members or others when making decisions.

• Be furnished with the name of the provider(s) and staff helping with your care.

• Accept or refuse any treatment by the clinic to the extent permitted by law and be informed of the medical consequences of such acceptance or refusal.

• Designate a representative to make healthcare decisions on your behalf.

• Privacy shall be respected to the extent consistent with providing adequate medical care to you, with the efficient administration of the clinic, and with applicable law.

• Discuss your concerns; your provider may ask another provider, medical assistant, or medical student to accompany them in the exam room.

• Change providers or transfer your care.

• Refuse to participate in any research program should one be offered.

• Examine your bill and receive an explanation of the charges, regardless of the source of payment of such bill. An itemized bill will be furnished upon request.

• Review your medical record and obtain a copy for a reasonable fee.

• Be involved in your care.

• Have any concerns, complaints, and grievances heard and addressed without fear of reprisals.

• Have the right to request a chaperone.

You, our patient, have the responsibility to:

• Provide Douglas Family Chiropractic with correct and complete information about past illnesses, hospitalizations, medications, allergies, and any other matters relating to your health.

• Inform Douglas Family Chiropractic if you need help understanding the information or instructions given to you by the staff or if you think you will be unable to carry out any particular instruction.

• Report any unexpected changes in your condition or concerns about your care.

• Follow the care, treatment, and service plans developed for you by your healthcare team.

• Keep all appointments and advise Douglas Family Chiropractic when you cannot keep an appointment.

• Arrive 15 minutes before your scheduled appointments to allow time to review any paperwork or visit-related information.

• As a courtesy to others, you will likely be rescheduled if you arrive at Douglas Family Chiropractic 15 minutes past your scheduled appointment time.

• Repetitive cancellations, no-shows, or lateness may result in discharge from the clinic.

• Be considerate of other patients, their visitors, and their property.

• Be considerate of Douglas Family Chiropractic staff and our property. Please note that we have a zero-tolerance policy regarding any verbally, physically, or mentally abusive or threatening behavior to any Douglas Family Chiropractic staff, providers, or other patients. Such behaviors will be grounds for terminating your care and therapeutic relationship with Douglas Family Chiropractic.

• Share any concern you may have if your provider asks another provider, chiropractic assistant, or chiropractic intern to accompany them in the exam room. This would occur when the provider requires support and/or if we have an intern training at our clinic.

• Provide complete and sufficient information necessary for the insurance processing of your bill.

• Assume the financial responsibility of paying for all services rendered through your insurance or taking personal responsibility to pay for any services not covered by insurance.

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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.

WHO IS COVERED BY THIS NOTICE

This notice describes the privacy practices of the affiliated physician practice plans of Chiropractic Solutions of Georgia, LLC., dba Douglas Family Chiropractic  including:

• Any health care professional authorized to enter information into your medical record.

• All employees and staff at Chiropractic Solutions of Georgia, LLC. dba Douglas Family Chiropractic 
  

OUR PLEDGE REGARDING MEDICAL INFORMATION

We are required by law to:

• make sure that your health information is kept private; 

• give you this notice of our legal duties and privacy practices; and

• follow the terms of the notice that is currently in effect. 

We understand that your health information is personal. We create a record of the care and services you receive.  We need this record to provide you with quality care and to comply with certain legal requirements. We are committed to protecting this information.

This notice will tell you about:

• the ways in which we may use and disclose your health information

• your rights; and

• our obligations regarding the use and disclosure of health information  

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

We may use or share your health information in certain ways.  We will explain how and when we may use or share your health information.  We are not able to list each specific way we may use or share your health information, but each situation will fall into one of the basic types of situations below:

1. For Treatment.  It is important that we be able to use or share your information to treat you.  We may share your information with doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you. We may share your information with healthcare providers for your treatment.

   For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process.  We may need to share your information in order to schedule you for surgery or a procedure. A healthcare provider may need to know about any drug allergies that you have in order to provide you with appropriate medication. 

2. For Payment We may use or share your health information so that we are paid for the cost of your care.  We may share your information with another provider so that they may be paid for services as well. We may bill, and share information with other providers, an insurance company, you, or a third party. 

   For example, we may need to give your health plan information about your diagnosis and treatment so your health plan will pay us or reimburse you for the care we provide.  We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.  We may also share your health information in order to facilitate payment to another provider who has participated in your care. 

3. Health-Related Benefits and Services We may use and disclose medical information to tell you about treatment options, health-related benefits, or services that may be of interest to you. 

4. Individuals Involved in Your Care or Payment for Your Care We may release medical information about you to a family member or other designated person who is involved in your medical care. We may also give information to someone who helps pay for your care.

   For example: We may need to tell the person who comes to pick you up after the appointment what he or she may need to do to help you once you get home.

In the event of an emergency, we may need to use or share information about you in order to inform your family or persons responsible for your care where you are, and your condition.  In addition, we may disclose medical information about you to an agency assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.

SPECIAL SITUATIONS:  Additional uses and disclosures for which authorization or opportunity to agree or object is not required by HIPAA.

1. Research It can help find cures for diseases and help you and many other people. Under certain circumstances, we may use and disclose medical information about you for research purposes. Often, you will need to give permission before we share your information with others for use in research. If your information is used, the researcher must keep your information safe and confidential. 

2. As Required by Law We will disclose medical information about you when required to do so by federal, state, or local law.

3. To Avert a Serious Threat to Health or Safety We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. 

4. Workers' Compensation We may release medical information to Workers' Compensation, as required by workers’ compensation laws. This program provides benefits for work-related injuries or illnesses.

5. Public Health Risks As required by law, we may disclose your health information to public health authorities for purposes related to preventing or controlling disease, injury, or disability; reporting medical device safety issues and adverse events to the federal Food and Drug Administration’s MedWatch program; and reporting disease or infection exposure.

6. Victims of Abuse, Neglect, or Domestic Violence We may disclose certain health information to government agencies authorized by law to receive reports of abuse, neglect, or domestic violence if we believe that you have been a victim.  

7. Health Oversight Activities We may disclose medical information to a health oversight agency for activities authorized by law.  These oversight activities include, for example, audits, investigations, inspections, and licensure.

8. Judicial and Administrative Proceedings We may disclose your health information in the course of an administrative or judicial proceeding, such as in response to a court order

9. Law Enforcement We may release medical information to a law enforcement official if required or permitted by law.   

10. Deceased Person Information We may release medical information to a coroner, medical examiner, or funeral director as necessary to carry out their duties. 

11. Specialized Government Functions We may release medical information about you to authorized federal officials for national security and intelligence, military, or veterans’ activities required by law. 

USES OF MEDICAL INFORMATION THAT REQUIRE AUTHORIZATION

In all other situations (situations that are not treatment, payment, health systems operations, or special situations, as we told you about above), we may only share information with your specific written authorization. You may revoke that authorization, in writing, at any time.  If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization, except to the extent that we already have used or disclosed your information.

YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU

Although the physical form of your medical information or designated record set is our business record and is the property of the health system, the information contained in those records is your information, and you have certain rights regarding that information.  

You have the following rights regarding medical information we maintain about you:

1. Right to Review and Copy You have the right to inspect and obtain a copy of medical information that may be used to make decisions about your care. 

   Usually, this information includes medical and billing records but does not include psychotherapy notes, information compiled for use in or created in anticipation of a civil, criminal, or administrative action or proceeding, or certain lab test results subject to the Clinical Laboratories Improvement Act of 1988. You must submit your request for your medical information in writing to the office manager of the office where you received your care.  If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request.

2. Right to Appeal a Denial of Access to Medical Information You have the right to access your medical information.  There are some limitations on that right.  If for clear treatment reasons, your health provider has determined that access to your health information is likely to have an adverse effect on you, the health care provider shall provide the record to a practitioner designated by you to help you with your review of the information.

   Your access is limited to your Designated Record Set.  Your designated record set is the information we use to make decisions about your care.  It does not include:

   • Information compiled for use in or created in anticipation of a civil, criminal, or administrative action or proceeding, or

   • Certain lab test results are subject to the Clinical Laboratories Improvement Act of 1988.

   • Other types of information that we did not use to make decisions about your health care.

3. Right to Amend  If you feel that the medical information we have about you is incorrect or incomplete, you may ask us to amend the information.  You have the right to request an amendment for as long as the information is maintained. We may deny your request if you ask us to amend information that:

   • is not part of the information which you would be permitted to inspect and copy; or

   • we believe is accurate and complete.

   Submit your request to the office manager of the office where you received your care.  Your request must be made in writing and include a reason that supports your request.

4. Right to an Accounting of Disclosures  You have the right to request an accounting of disclosures.  An accounting of disclosures is a listing of releases of your health information that we have made for the “Special Situations” listed in this Notice.  We must document these disclosures and provide you with an accounting of them if we did not obtain your authorization before we released your information.  You must submit your request in writing to the HIPAA Privacy Contact in the office where you were seen. 

   Your request must:

   • tell us the calendar dates you want to see. The time period cannot include more than six years of information, and cannot begin prior to April 14, 2003. 

   • indicate in what form you want the list (paper copy or electronic).  

   Charges:  There will be no charge for the first list you request within a 12-month period.  We may charge you for the costs of providing any additional lists.  We will notify you of the cost involved.  You may choose to withdraw or modify your request at that time before any costs are incurred.

5. Right to Request Restrictions  You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment, or health care operations. We are not required to agree to your request.  If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.  You must make your request for any restrictions in writing to the office manager of the office where you received your care.  In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply (for example, disclosures to your spouse). 

6. Right to Request Confidential Communications  You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.  For example, you can ask that we only contact you at work or by mail. You must make your request for confidential communications in writing to the office manager where you received your care.  We will not ask you why you are making this request.  We will accommodate all reasonable requests.   Your request must specify how or where you wish to be contacted.  For example, if you wish to be contacted by telephone, be sure to provide an appropriate telephone number.

7. Right to a Paper Copy of This Notice  You have the right to a paper copy of this notice.  You may ask us to give you a copy of this notice at any time.  Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.  Contact a member of the office staff for a copy.

8. CHANGES TO THIS NOTICE  We reserve the right to change this notice.  We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future.  Current copies of this notice will be available at our office. The effective date of the notice is September 1, 2023.

9. COMPLAINTS  If you believe your privacy rights have been violated, you may file a complaint with our health system by either contacting the Office Manager at the office where you received your care or with the U.S. Office of Civil Rights, Washington, DC. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

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