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HIPAA Information and Consent Form
We have adopted the following policies:
1. Patient information will be kept confidential except as is necessary to provide services or
to ensure that all administrative matters related to your care are handled appropriately.
This specifically includes the sharing of information with other healthcare providers,
laboratories, health insurance payers as is necessary and appropriate for your care. Patient
files may be stored in open file racks. The normal course of providing care means that
such records may be left, at least temporarily, in administrative areas such as the front
office, etc. Those records will not be available to persons other than office staff. You
agree to the normal procedures utilized within the office for the handling of charts,
patient records, PHI and other documents or information.
2. It is the policy of this office to remind patients of their appointments. We may do this by
telephone, email, text messaging, or other means. We may send you other
communications informing you of changes to office policy and new technology that you
might find valuable or informative.
3. You understand and agree to inspections of the office and review of documents which
may include PHI by government agencies or insurance payers in normal performance of
4. You agree to bring any concerns or complaints regarding privacy to the attention of the
office manager or the provider.
5. Your confidential information will not be used for the purposes of marketing or
advertising of products, goods or services.
6. We agree to provide patients with access to their records in accordance with state and
7. We may change, add, delete, or modify any of these provisions to better serve the needs
of both the practice and the patient.
8. You have the right to request restrictions in the use of your protected health information
and to request change in certain policies used within the office concerning your PHI.
However, we are not obligated to alter internal policies to conform to your request.
Client Informed Consent and Financial Obligations
the undersigned client, consent to the treatment(s) provided by Structura Body Therapies. I understand that my condition may necessitate modification from time to time of the type of treatment(s) rendered and the portions of my body that may be examined. I understand and consent to clinic staff providing me with verbal descriptions, when there are changes to my treatment(s). If consent is not given I will immediately inform clinic staff. There are times when individuals other than staff may see me receive treatment at the clinic or overhear of my condition or insurance. I Consent to others perceiving these interactions at the clinic. If additional privacy is required, I will inform the clinic staff.
A finance charge of 1 ½% per month (annual percentage rate 18%) of the unpaid balance will be added monthly. Should collection become necessary, the responsible party agrees to pay a collection fee of up to 40% and all legal fees of collection, with or without suit, including attorney fees and court costs.
I understand and agree that my appointment, be it cash pay, co-payment, co-insurance and/or deductibles are due and payable at the time of service, and I may receive a bill for any amounts due that are not collected at the time of service related to insurance.
I understand that Structura Body Therapies can bill my insurance as a courtesy and any services not covered through my benefits, as well as any applicable co-payments and deductibles are my responsibility.
I understand that an inactive insurance card, no insurance, no insurance card, or insurance we are not a participating provider for will render me responsible for payment for services.
I understand that if I am not using insurance I am responsible for the full cash price of my appointment at the time of service.
The Insured/Guardian/Client is advised that a copy of the client’s insurance card and identification is required to submit a claim.
The Insured/Guardian/Client is advised that this document will become a part of the client’s medical record and billing statements will be sent for services should any of the above occur.
The Insured/Guardian/Client is also advised that most carriers have a claim filing limit. Correct insurance information received greater than 60 days from the date of this document may be denied by their carrier as untimely and the insured/guardian/client will be held responsible for any balance.