So we may better serve you, please choose your preferred method(s) of contact,
New federal regulations regarding Electronic Health Records now require that we document patient sex, ethnicity, preferred language, and tobacco use. (not required, but preferred).
Please review the list of symptoms shown below,and select ANY that you are CURRENTLY experiencing.
Click Here to View or Click Here to Download Matteo Chiropractic's (HIPPA) NOTICE OF PRIVACY PRACTICES.
I understand that my protected health information will be kept private and confidential in accordance with the privacy practices of Matteo Chiropractic, PLLC. Matteo Chiropractic has a detailed document titled “Notice of Privacy Practices”, which contains additional, detailed information about the policies and practices protecting patient privacy.I understand that I have the right to request, and to read the “Notice of Privacy Practices” before signing this Acknowledgement or any time thereafter. Within the "Notice of Privacy Practices" is contained a complete description of my privacy/confidentiality rights.By entering my first and last name below, and selecting the "I understand and agree to the Notice of Privacy Practices" check-box indicates that I have been informed of, and understand my rights to review the “Notice of Privacy Practices”, and that I agree to the “Notice of Privacy Practices” for Matteo Chiropractic, PLLC.
I understand that an insurance company may not pay the full amount of my charges, and that I may be responsible (as a patient, spouse, or the parent of a minor child) for the amount not paid.I also understand that if I do not have health insurance coverage, or have not provided current or accurate insurance, that I am responsible for payment of any and all charges.If I have overpaid a balance due on any individual charge billed by Matteo Chiropractic, PLLC, I agree that this overpayment may be transferred to pay on a balance due for another charge unless other arrangements are formally discussed and planned with a member of Matteo Chiropractic's billing staff.
I hereby assign, transfer, and convey all my rights, title and interest to medical reimbursement under my insurance policy(s) to Matteo Chiropractic, PLLC for professional service(s) rendered in the course of any examination or treatment.This authorization shall remain valid until revoked, by me, in writing.It is understood, whether I sign as agent, patient, or as guarantor, that I am directly responsible for, and will pay for any and all services rendered and not covered by my health insurance benefit plan provider.
I authorize the health care providers and staff of Matteo Chiropractic,PLLC to release any and all medical, financial, and demographic information that is deemed necessary by my health care provider for the continuation of my health care to other health care providers, facilities, agencies, and financial institutions.This authorization will remain in effect until revoked, in writing, and I understand my right to refuse this provision on a case by case basis, when, I notify Mateo Chiropractic, PLLC in writing of the exception in advance.
If You Would Like a Copy of This Form Sent to Your Email, Please Enter Your Email Address Below.