PATIENT CONSENT AUTHORIZATION
CONSENT FOR TREATMENT:
I voluntarily consent to the rendering of care, including treatment and performance of diagnostic procedures I understand that I am under the care and supervision of the attending physician and it is the responsibility of the staff to carry out the instructions of such physicians.
RELEASE OF INFORMATION:
By signing the form, you are granting consent to BODY BALANCE CHIROPRACTIC & WELLNESS CENTER to use and disclose your protected health information for the purposes of treatment, payment and health care operations. Our Notice of Privacy Practices provides more detailed information about how we may use and disclose this protected health information. You have a legal right to review OUf Notice of Privacy Practices before you sign this consent, and we encourage you to read it in full. Our notice of Privacy Practices is subject to change. If we change our notice you may obtain a copy of the revised notice by telephoning our office at 281-890-5599. You have a right to request us to restrict how we use and disclose your protected health information for the purposes of treatment, payment or health care operations. We are not required by law to grant your request. However, if we do decide to grant your request, we are bound by our agreement. You have the right to revoke this consent in writing, except to the extent we already have used or disclosed your protected health information in reliance on your consent.
MEDICARE AND MEDICAID CONSENT TO RELEASE INFORMATION:
I certify that the information given by me in applying for payment under Title XVIII and/or Title XI of the Social Security Act is correct, I authorize my holder of medical or other information about me, to release to the Social Security Administration or its intermediary carriers, any information needed for this or related Medicare or Medicaid claim.
INFORMED CONSENT TO PARTICIPATE IN ACTIVE REHABILITATION
THE GOALS OF TIlE REHABILITATION PROGRAM INCLUDE:
I. Determining the cause and extent of your problem,
2. Providing a therapeutic exercise program to strengthen you, increase your cardiovascular endurance, range of motion and flexibility, and decrease your pain.
3. Return your to full-duty, non-restricted work status and lifestyle.
THE EQUIPMENT USED TO TEST YOU AND TIlE PROCESS WE WILL BE USING WILL BE EXPLAINED TO YOU:
Your participation in the rehabilitation program is voluntary. You can stop at any point in the program. Should you stop your program, we are obligated to notify your doctor, insurance company, attorney, and DVR manager, if it is applicable. If at any point during the evaluation or rehabilitation process you have any questions, we will answer them to the best of our ability or refer you to someone more qualified. Please be advised that there are no guarantees that your personal goals and orthose listed above will be met to your satisfaction. The success of any rehabilitation process lies in the combined effort of you and your provider. The "team" approach has the best chance of attaining your goals, so please ask as many questions as necessary for you to gain the maximum benefit from your rehabilitation program. Since the process of strengthening and conditioning are a form of "controlled strain", there is a chance of aggravation or injury. It is therefore imperative that you communicate to your provider any aggravation or injury that you may observe during the rehabilitation process. For example, the best exercise for you, if performed too early in your condition, may be your worst enemy if performed too soon. Communication with your provider will help put into perspective problems that may occur. Failure to discuss problems may only foster additional problems down the road. Research concerning the rehabilitation program and results may be conducted. Data will be used from the participant's evaluations and exercise program. No names will be used and all information is strictly confidential.
