Section One: Personal Information
ASSIGNMENT AND RELEASE
I, the undersigned certify that I (or my dependent) understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the release of
information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
**Please Refrain From Wearing Perfume, Cologne or Other Scents**
Payment is required at the time of service and you are responsible for all fees.
Please provide at least 24 hour notice for all cancellations to make time available to other clients.
Failure to provide at least 24 hours notice of cancellation or a no call/no show may result in a full session fee. Please be aware that the appointment time starts at the designated time. If a client arrives late to their appointment, they will be required to pay full session fee regardless of how much time is
left of their appointment.
MY SIGNATURE CONFIRMS THAT I AM AWARE OF AND AGREE TO THE ABOVE.
Please check any of the following conditions below that currently affect you or that you have experienced in the last 5 years.
The above information is accurate and true to the best of my knowledge. I understand that my therapist does not diagnose disease, prescribe medications, or
manipulate bones. I further understand that CranioSacral Therapy is not a substitute for medical attention or examination. I take responsibility for alerting
my therapist to any physical, mental or emotional changes that occur with my health.
I grant permission to the providers at BALANCED BEING, INC. to perform examinations and procedures as may be deemed professionally necessary or advisable for my treatment.
CONSENT FOR RELEASE OF INFORMATION
I authorize BALANCED BEING, INC. to:
Release any and all of my insurance and medical information to other health care providers, my insurance company, Medicare or any third party payer to facilitate health care, processing claims and audit of payments. I understand that the information released may include records in these subjects area: HIV/AIDS, sexually transmitted disease, medical and drug or alcohol abuse treatment.
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
We keep a record of the health care services we provide for you. You may ask to see and copy that record. You may also ask to correct that record. We will not disclose your record to others unless you direct us to do so or
unless the law authorizes or compels us to do so. Our Notice of Privacy Practices describes in more detail how your health information may be used and disclosed and how you can access your information.
ADDITIONAL DISCLOSURE AUTHORITY
In addition to the allowable disclosures described in the Notice of Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the persons indicated below.
By my signature below I acknowledge receipt of the Financial Policy and Notice of Privacy
Practices and have read and understand them. These consents will remain in effect until revoked by me in writing.
NOTICE OF PRIVACY PRACTICES
This notice describes how medical information about you may be used and disclosed,
and how you can get access to this information. Please review carefully.
Balanced Being, Inc. respects your privacy. We understand that your personal health information is very
sensitive. We will not disclose your information to others unless you tell us to do so, or unless the law authorizes or compels us to do so.
The law protects the privacy of the health information we create and obtain in providing our care and services to you. For example, your protected health care information includes your symptoms, test results, diagnosis, and
treatment, health information from other providers, billing and payment information relating to these services.
Federal and state law allows us to use and disclose your protected health information for the purposes of treatment and health care operations. State law requires us to get your authorization to disclose this information for payment purposes.
Examples of Use and Disclosures of Protected Health Information for Treatment, Payment, and Health Operations.
- Information obtained by any member of our health care team will be recorded in your medical record and used to help decide what care might be right for you.
- We may also provide information to others providing your care. This information help them stay informed about your care
- We request payment from your health insurance plan. Health plans need information from us about your
medical care. Information provided to health plans may include your diagnosis, procedures performed, or recommended care.
For Health Care Operations:
- We use your medical records to assess quality and improve services.
- We may use and disclose medical records to review the qualification and performance of our health care providers and to train staff.
- We may contact you to raise funds.
- We may use and disclose your information to conduct or arrange for services including:
- Medical quality review by your health plan.
- Accounting, legal, risk management, and insurance services.
- Audit functions, including fraud, abuse detection and compliance programs.
Your Health Information Rights
The health and billings records we create and store are the property of this practice/health care facility. The Protected Health Information (PHI) in it, however, generally belongs to you.
You have right to:
- You have the right, which may be restricted only in certain limited circumstances, to inspect and copy
you PHI that we maintain. We may charge a reasonable cost based fee for copies. You will need to make this request in writing. We have a form available for this type of request.
- Right to Amend: If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information, although I am not required to agree to the amendment.
- Right to an Accounting Disclosure: You have the right to request a copy of the required accounting of disclosures that we make of your PHI.
- Right to Request Restrictions: You have the right to request restrictions or limitation on the use or disclosure of your PHI for treatment, payment or health care operations. We are not required to agree to
- Right to Request Confidential Communication: You have the right to request that we communicate with you in a certain way or at a certain location. We will accommodate reasonable requests and will not ask why you are making the request.
- Right to a Copy of this Notice: You have a right to a paper copy of this notice.
- Right to Complaint: You have the right to file a complaint with me or with the Secretary of State if you believe I have violated your privacy rights. We will not retaliate against you for filing a complaint.
- You have the right to cancel prior authorizations to use or disclose health information by giving us a written revocation. Your revocation does not affect information that has already been released. It also
does not affect any action taken before we have the revocation. Sometimes, you cannot cancel an authorization if its purpose was to obtain insurance.
We are required to:
- Keep your Protected Health Information private.
- Give you this notice.
- Follow the terms of this notice:
We have the right to change our practices regarding the Protected Health Information we maintain. If we make changes, we will update this notice, you may receive the most resent copy of this notice by calling or visiting our office to pick one up.
You have the right to object to this or disclosure of your information. If you object, we will not use or disclose it.