New Patient Agreement for Soul Shine Wellness

AUTHORIZATION FOR MEDICAL, HEALTH AND/OR NUTRITION SERVICES

Pursuant to this Client Registration Agreement, I/we authorize Soul Shine Family Chiropractic to administer such chiropractic, health care and/or nutrition services, treatments and procedures for me or my family members as the doctor deems appropriate and necessary under the applicable circumstances. I/we understand that the doctor will prescribe an integrative program that may include chiropractic, conventional health care, nutritional therapies, functional medicine and other elements of integrative medicine.

I/we understand that if any explanations as to benefits and/or risks and dangers of the prescribed treatments or services are unclear, it is my responsibility to ask for clarification before giving my consent. I/we understand that there are no warranties, representations or assurances of successful outcomes for me or my family members. Nevertheless, I desire to pursue integrative medical treatment or nutrition services for myself or my family members after reviewing the information herein and receiving answers to any questions related to this Agreement. As a patient or family member seeking medical, health care and/or nutrition services, I/we understand that I/we are ultimately responsible for selecting and approving recommended treatments and services (or rejecting recommended treatments/services).

I/we will report to Soul Shine Family Chiropractic any matters arising out of treatments or services and schedule a consultation to conduct appropriate follow-up. I/we will promptly seek care from Soul Shine Family Chiropractic or another medical facility if any of us experience any unanticipated effects associated with treatments and services or if the treated condition worsens. If a medical emergency arises, I/we will call 911 or visit the nearest hospital emergency room. I/we understand that Soul Shine Family Chiropractic provides a consultation-only service and does not have urgent care or on-call duties. Patients are expected to have a relationship with a primary medical doctor separate from Soul Shine Family Chiropractic.

APPOINTMENTS AND CANCELLATION POLICY

I/we understand that my/our appointment time with Soul Shine Family Chiropractic is reserved exclusively for my/our care for the duration of all scheduled visits. I/we agree to receive appointment reminders by email and/or text messaging. I/we understand that these email and/or text reminders sent by Soul Shine are a courtesy service, and if for any reason, I do not receive the reminder message, that I/we are still responsible to remember and attend the scheduled appointment on time. I/we understand that I/ we are expected to keep all appointments as scheduled in order to ensure maximum progress in connection with treatment and care and that if I/we are late for an appointment, the visit will end at the scheduled time and I/we will be responsible for the cost of the full visit. If I/we need to cancel or reschedule an appointment, I/we will call during business hours at least two business days in advance. No charge will apply in this situation. As an illustration, if an appointment is on a Monday, canceling during business hours on the prior Thursday provides two business days’ notice. I/we understand that if I/we cancel an appointment during business hours only one business day prior to the scheduled visit, or if I/we fail to show or cancel on the day of the appointment, I/we will be charged a fee equal to 50% of the cost of the scheduled appointment for the first occurrence, and the full visit fee will be charged for any subsequent missed appointment.

TELEPHONE AND EMAIL CONSULTATION POLICY

Soul Shine Family Chiropractic checks telephone and email messages during business hours and responds to them on a regular basis throughout the week. I understand this system is for non-urgent messages only, and allow up to 2 working days for response. If our questions and/or concerns are more complex, a follow-up appointment may be requested, and I/we will be responsible for the standard follow-up fees. I/we authorize this to be charged to the credit card on file. If I/we are experiencing a medical emergency, I/we will call 911 or go directly to an emergency room. In general, Soul Shine Family Chiropractic does not follow-up with telephone messages and/or emails that occur after hours, on weekends or holidays. By sending an email, I/we acknowledge and agree that a prompt reply is NOT required or expected and acknowledge that I/we will not use email communications to deal with emergencies or other time sensitive issues. I/we also understand and agree that email communications may not be secure and the confidentiality of emails cannot be assured or guaranteed, but agree that this is my/our risk with respect to all email communications. Soul Shine Family Chiropractic may keep copies of email communications, and such messages may be included in the health record.

INSURANCE RESPONSIBILITY AND CLAIMS MANAGEMENT

I/we acknowledge that Soul Shine Family Chiropractic strongly recommends that all patients maintain health insurance coverage. It is my/our responsibility to know my/our plan benefits and to obtain insurance advice from my/our own licensed insurance agent, broker or human resource professional. Given the uncertainty that pervades insurance decisions, I/we agree that Soul Shine Family Chiropractic is not responsible for any information related to my/ our insurance that turns out to be incorrect. I/we agree that Soul Shine Family Chiropractic is not obligated to take action on my/our behalf against an insurance company related to any insurance claim or payment. I/we understand that I/we will receive a superbill or claim form showing the cost and nature of services and it will be my/our responsibility to submit the claim to the insurer.

I/we understand that Soul Shine Family Chiropractic does not participate in insurance plans or accept assignment from any other payer including employers or insurers. I/we will be responsible for all charges and fees incurred for treatments or services rendered, even if my/our insurance company determines that any services are non-covered or excluded. I/we understand that insurance reimbursement may not be available for some services. My/our insurer may not pay for office visits, telephone consultations or emails including but not limited to circumstances where the focus of the consultation is on prevention, education, wellness, nutrition advice, herbal medicine, etc. Some of the lab tests that are ordered, particularly those that are used in support of wellness consultations or are kits sent to labs using innovative approaches to diagnostics, may also not be reimbursed.

FINANCIAL RESPONSIBILITY AND AUTHORIZATION FOR PAYMENT

I/we understand that payment for all services, treatments, products and other fees will be required at each visit and after each other service related matter and authorize Soul Shine Family Chiropractic to charge all outstanding balances to my/our credit card indicated below. I/we authorize this credit card (and all substituted credit cards) to be used to guarantee and pay for late cancellations, missed appointment, and/or unpaid balances including those related to office visits, telephone/e-mail consultations, charges for products and supplements and miscellaneous costs. I/ we agree that if the credit card on file does not accept the charge, I/we will immediately make payment to Soul Shine Family Chiropractic for the amount due and will provide an alternative Visa/MasterCard account number upon request if my/our current credit card account is over limit, canceled or expired. I understand that fees may increase periodically based on costs relevant to the medical practice.

HEALTH INFORMATION RELEASE AUTHORIZATION AND PRIVACY PRACTICES

Soul Shine Family Chiropractic is permitted by applicable federal and state privacy laws to use and disclose my/our protected health information (PHI) for treatment, payment and health care operations and for other purposes as required or permitted by law. Our Terms of Acceptance, as it may be amended from time to time (“Terms of Acceptance”), is available by email upon request or in person at the office. I/we authorize Soul Shine Family Chiropractic to release my/our medical records in connection with treatment, payment for services and its health care operations and as provided in the Terms, which is incorporated into this Agreement by reference. I/we understand that the Terms may be modified or amended on the basis described in the Terms. I/we also authorize any physician or health care provider to release their protected health information records to Soul Shine Family Chiropractic. This authorization extends to my protected health information records, if applicable.

COMPLAINTS, COMMENTS AND QUESTIONS

Soul Shine Family Chiropractic is committed to providing quality care and resolving favorably any complaint, problem, question or unsatisfactory experience that might occur in connection with medical or nutritional services. It the policy of Soul Shine Family Chiropractic that (i) if any person has a complaint or problem or unsatisfactory or negative experience related to our business, services or products, such person must bring the matter to our attention privately, by email, phone or in person; and (ii) Soul Shine Family Chiropractic will investigate any such matter and attempt in good faith, without any retaliation, to reasonably resolve the matter.

By registering, I/we agree to comply fully with this policy. This is my/our sole and exclusive remedy in connection with any complaint or problem or unsatisfactory or negative experience that I/we may have with Soul Shine Family Chiropractic, services or products (other than remedies available in a court of law or pursuant to arbitration). I/we further agree not to publish, post, transmit, disclose or distribute (directly or indirectly), in or on any publicly available or accessible forum, newspaper, magazine, electronic publication, blog, web site, on-line users group or similar device, document or medium, any negative, false or disparaging comment, belief, opinion, experience or information (or that could reasonably be so construed), without prior written consent. I/we acknowledge and agree that these terms are reasonable and that any breach or violation of this paragraph will cause significant damage and expense that would be impossible or highly impractical for soulshinechiro.com to quantify and establish. Consequently, I/we agree that upon each breach or violation of this paragraph, I/we will be obligated, jointly or severally, to pay liquidated damages in the amount of $200.00 per day per violation until the breach or violation has been cured to satisfaction.

DURATION OF AGREEMENT, REVOCATIONS OF AUTHORIZATIONS AND AMENDMENTS

I/we may revoke the medical records release authorization in writing at any time and Soul Shine Family Chiropractic will attempt to accommodate all reasonable requests. However, I understand that in some circumstances related to treatment, payment or health care operations, Soul Shine Family Chiropractic may not be able to accommodate such requests. I further agree that, in no event, will any revocation of a prior authorization affect any of my other obligations in this Agreement. The rights and obligations of the parties herein shall be fully applicable and the respective rights and obligations of the parties shall survive expiration, cancelation or termination of this Agreement for any reason. I/we also certify that my family or I am enrolled in this practice to receive medical and health care and for no other purpose. This Agreement and the Notice, along with any agreement to arbitrate, reflects the entire and exclusive agreement between us and supersedes any prior or other contemporaneous agreement. This Agreement may only be amended by a written document signed by Soul Shine Family Chiropractic and the registering patient or patient’s legal advocate.