Welcome to Kirkland Spine _ Wellness - Vortala

Document Sample
Welcome to Kirkland Spine _ Wellness - Vortala Powered By Docstoc
					            Welcome to Kirkland Spine & Wellness
Patient Information
Thank you for choosing Kirkland Spine & Wellness for your chiropractic needs. Please complete this form in
ink. If you have any questions or concerns, please do not hesitate to ask for assistance. We are happy to help.
(please print clearly)
Name: _______________________________________________________ SS/HIC/Patient ID #: ___________________
              First                  Middle Initial                Last

Address: ___________________________________ City: ____________________ State: _____ Zip Code: __________
Sex: ❏ Female ❏ Male         Birthdate: _________________ E-mail: _________________________________________
Home Phone: (_____)______________ Cell Phone: (_____)______________ Work Phone: (_____)______________
Do you prefer to receive calls at:      ❏ Home            ❏ Work          ❏ Cell      ❏ No Preference
   ❏ Married ❏ Widowed          ❏ Single              ❏ Minor   ❏ Separated        ❏ Divorced   ❏ Partnered for ____ years
Patient Employer/School: ________________________________________ Occupation: _________________________
Employer/School Address: _____________________ City: ____________________ State: _____ Zip Code: __________
Spouse or parent’s name: ___________________ Employer: ______________ Work Phone: (_____)______________
Whom may we thank for referring you to us? _____________________________________________________________
Person to contact in case of emergency: ____________________________________ Phone: (_____)______________

Responsible Party
Name of person responsible for this account: _____________________________________________________________
Relationship to patient: _________________________________________________ Phone: (_____)______________
Address: ___________________________________ City: ____________________ State: _____ Zip Code: __________
Name of employer: ________________________________________________ Work Phone: (_____)______________

Insurance Information
Name of insured: _______________________________ Relationship to patient: ________________________________
Birthdate: ______________________ Social Security#:: __________________ Date employed: ___________________
Name of employer: ________________________________________________ Work Phone: (_____)______________
Address: ___________________________________ City: ____________________ State: _____ Zip Code: __________
Insurance Co.: _____________________ Phone: (_____)______________ Group #: _____ Employer #: ____________
Insurance Co. address: ________________________ City: ____________________ State: _____ Zip Code: __________
How much is your deductible? ________ How much have you used? ___________ Max. annual benefit? ____________
Do you have additional insurance?               ❏ Yes       ❏ No          If Yes, please complete the following:
Name of insured: _______________________________ Relationship to patient: ________________________________
Birthdate: ______________________ Social Security#:: __________________ Date employed: ___________________
Name of employer: ________________________________________________ Work Phone: (_____)______________
Address: ___________________________________ City: ____________________ State: _____ Zip Code: __________
Insurance Co.: _____________________ Phone: (_____)______________ Group #: _____ Employer #: ____________
Insurance Co. address: ________________________ City: ____________________ State: _____ Zip Code: __________
How much is your deductible? ________ How much have you used? ___________ Max. annual benefit? ____________

Reason for visit: __________________________________ When did you first notice the symptoms? ___________________
Is the condition getting progressively worse? ___________ Where specifically is the problem(s) located? ________________
Which activities are difficult to perform?     ❏ Sitting ❏ Standing ❏ Walking ❏ Bending ❏ Lying down ❏ Other
Type of pain: ❏ Sharp              ❏ Dull          ❏ Throbbing      ❏ Numbness     ❏ Aching       ❏ Shooting
                 ❏ Burning         ❏ Tingling      ❏ Cramps         ❏ Stiffness    ❏ Swelling     ❏ Other
Rate the severity of your pain. (1 = mild pain or discomfort, to 10 = severe pain) 1 2 3 4 5 6 7 8 9 10
Is the pain constant or does it come and go? __________________________________________________________________
What treatment have you received for your condition?
    ❏ Medication        ❏ Surgery        ❏ Physical Therapy       ❏ Other __________________________________________
Name and address of other doctor(s) who have treated you for your condition:

Health History Check only those conditions which are applicable:
   ❏   AIDS/HIV                    ❏   Cataracts                          ❏   Hepatitis            ❏   Osteoporosis             ❏ Suicide Attempt
   ❏   Alcoholism                  ❏   Chemical Dependency                ❏   Hernia               ❏   Pacemaker                ❏ Thyroid Problems
   ❏   Allergy Shots               ❏   Chicken Pox                        ❏   Herniated Disc       ❏   Parkinson’s Disease      ❏ Tonsillitis
   ❏   Anemia                      ❏   Depression                         ❏   Herpes               ❏   Pinched Nerve            ❏ Tuberculosis
   ❏   Anorexia                    ❏   Diabetes                           ❏   High Cholesterol     ❏   Pneumonia                ❏ Tumors, Growths
   ❏   Appendicitis                ❏   Emphysema                          ❏   Kidney Disease       ❏   Polio                    ❏ Typhoid Fever
   ❏   Arthritis                   ❏   Epilepsy                           ❏   Liver Disease        ❏   Prostrate Problems       ❏ Ulcers
   ❏   Asthma                      ❏   Fractures                          ❏   Measles              ❏   Prosthesis               ❏ Vaginal Infections
   ❏   Bleeding Disorders          ❏   Glaucoma                           ❏   Migraine Headaches   ❏   Psychiatric Care         ❏ Venereal Disease
   ❏   Breast Lump                 ❏   Goiter                             ❏   Miscarriage          ❏   Rheumatoid Arthritis     ❏ Whooping Cough
   ❏   Bronchitis                  ❏   Gonorrhea                          ❏   Mononucleosis        ❏   Rheumatic Fever          ❏ Other ___________
   ❏   Bulimia                     ❏   Gout                               ❏   Multiple Sclerosis   ❏   Scarlet Fever            ___________________
   ❏   Cancer                      ❏   Heart Disease                      ❏   Mumps                ❏   Stroke                   ___________________
Dates of last exams: _____________________________________________________________________________________
(Woman) Are you pregnant?         ❏ Yes ❏No            Nursing? ❏Yes ❏No        Taking Birth Control Pills? ❏Yes ❏No
List any types of surgeries which you have had and the dates which they occurred: ___________________________________
Please list all medications you are currently taking: ____________________________________________________________
Allergies: _____________________________________________________________________________________________

Daily Habits
What type of exercise do you perform on a daily basis? ❏ None       ❏ Moderate       ❏ Heavy
What do your daily work habits include? ____________________________________________________________________
What vitamins do you currently take? ___________________ Nutritional supplements (if any)? ________________________
Do you smoke? ❏ Yes ❏ No             How much per day? ______________________________________________________
How much liquor do you consume weekly? _________ How many caffeinated beverages do you consume daily? _________

Certification and Assignment
To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform
my doctor if I, or my minor child ever have a change in health.
I certify that I, and/or my dependent(s), have insurance coverage with _____________________________________________
and assign directly to Dr. Jeff Bowers all insurance benefits, if any, otherwise payable to me for services rendered. I understand
that i am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all
insurance submissions.
Dr. Jeff Bowers may use my health care information and may disclose such information to the above-named Insurance
Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the
benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the
date signed below.
                        Signature of Patient, Parent, Guardian or Personal Representative                                          Date

                    Please print name of Patient, Parent, Guardian or Personal Representative                             Relationship to Patient
                                          Kirkland Spine & Wellness
                                               Dr. Jeff Bowers
                                 Informed Consent to Chiropractic Care & X-ray

Every type of health care is associated with some risk of a potential problem. This includes chiropractic health
care. We want you to be informed about potential problems associated with chiropractic health care before
consenting to treatment. This is called INFORMED CONSENT.

Chiropractic adjustments are designed to improve the mobility (movement) and alignment of spinal joints. This
is typically accomplished with the doctor’s hands or with the use of hand-held instruments or tables.
Frequently, adjustments create a “pop” or “click” sound/sensation in the area being treated. The sound is due
to a change in pressure of the vertebral joints. The following is a list of potential risk associated with
chiropractic treatment and adjustments.

Stroke: Some types of manipulations of the neck have been suggested to be associated with injuries to the
arteries the neck, leading to or contributing to serious complications, including strokes. Even that simple
statement has been the subject of disagreement. Based on current published findings, the risk of stroke
associated with chiropractic adjustments is as follows:

               Spine 1999;24(8): 785-794, JACA 199;36(9):42-47 “Strokes caused by adjustments are an extremely rare event.
                Estimates show that an adverse reaction to neck adjustment occurs on the order of 1 per 500,000 to 1 per 4 million

               A comparable treatment for neck dysfunctions is the use of anti-inflammatory/pain killers (Advil, Motrin, Nuprin, and
                Aspirin) medications. Serious adverse effects can occur as a result of this treatment. Studies (JAMA 1998;279:1200-
                show that 16,500 people die every year as a result of gastrointestinal bleeding from taking there anti-inflammatory
                medications and show that adjustments are “several hundred times” safer and that the risk of complications are 4%
                while chiropractic adjustments show a .001% risk.

               Even though some people claim there us a direct relationship between adjustments and stroke, other researchers
                say that the evidence for a direct link is not there Dr. Scott Haldemen MD, Ph.D., says that “vertebrobasilar artery
                dissection (injury) after neck movement, trauma, or manipulations should be considered a rare, random,
                unpredictable, complication associated with these activities…” (Spine 1999;24(8): 785-794)

Disc Herniations: Disc Herniations that create pressure on the spinal nerve or on the spinal cord are frequently
and successfully treated by chiropractors and chiropractic adjustments, traction, etc. This includes both the
neck and lower back. Yet, occasionally, chiropractic treatment will aggravate the problem and could
potentially increase the symptoms. These problems occur so rarely that there are no available statistics to
quantify their probability.

Soft Tissue Injury: The term “soft tissue” primarily refers to muscles, ligaments, tendons, etc. While muscles
function to move bones, ligaments function to provide support, stability and restrict movement. Rarely a
chiropractic adjustment, traction, massage, etc. may cause injury to muscle/ligament fibers. The result is a
temporary increase in pain and necessary treatments for resolution, but there are no long-term effects for the
patient. These problems occur so rarely that there are no available statistics to quantify their probability.

Rib Fractures: The ribs are found only in the thoracic spine of mid-back. They extend from your back to your
front chest are. Rarely, a chiropractic adjustment will crack a rib bone, and this is referred to as
                                        Kirkland Spine & Wellness
                                             Dr. Jeff Bowers
                               Informed Consent to Chiropractic Care & X-ray

fracture. This occurs only on patients that have weakened bones from such things as osteoporosis.
Osteoporosis can be noted on our
x-rays. These problems occur so rarely that there are no available statistics to quantify their probability.

Soreness: It is common for chiropractic adjustments, traction, massage, exercise, etc. to result in a temporary
increase in soreness in the region being treated. This is nearly always a temporary symptom that occurs while
your body is undergoing therapeutic or structural change. It is not dangerous, but please do tell your doctor
about it.

Other problems: There may be other problems or complications that might a rise form chiropractic treatment
other than those noted above. These other problems or complications occur so rarely that it is not possible to
anticipate and/or explain them all in advance of treatment.

                                                 X-RAY CONSENT

The doctor has explained that the purpose of the x-rays about to be taken is to analyze the spine for structural
and/or mechanical problems and to determine the appropriateness of chiropractic spinal adjustments. If the
doctor discovers a non-chiropractic “unusual findings” when reviewing this x-ray, you will be informed. You
then can determine if you should seek the services of an additional health care provider for advice, diagnosis,
or treatment for the unusual findings. Understand that seeking advice from other type of health care provider
should not interfere with the spinal corrective care provided by this office.

I fully understand the above and consent to chiropractic spinal x-rays.

I hereby request and consent to the performance of chiropractic adjustments and other chiropractic
procedures including various modes of therapy modalities (including rehabilitative structural traction) and
diagnostic x-rays, on myself (or on the patient names below for whom I am legally responsible) by the licensed
doctors of chiropractic of Kirkland Wellness & Spine or any doctor who now or in the future, works as a relief

I have had an opportunity to discuss with my doctor the nature and purpose of chiropractic adjustments and
other procedures and understand that spinal manipulations involves the doctors placing his or her hands on
my spine and delivering quick thrusts or impulse to involved area(s). I also understand and am informed that,
as in the practice of medicine, in the practice of chiropractic there are some risks to treatment including, but
not limited to:
fractures, disc injuries, strokes, dislocations, sprains and soreness. I do not expect the doctor to be able to
anticipate and explain all risks and complications. I also wish to rely upon the doctor to exercise judgment
during the course of procedure which the doctor feels at the time, based upon the facts then known to him or
she is my interest.

Chiropractic is a system of health care delivery and therefore, as with many health care delivery system we
cannot promise a cure for any symptom, disease, or condition as a result of treatment in the clinic. We will
always give you our best care, and if results are not acceptable, we will refer you to another provider who we
feel will assist your situation.
                                           Kirkland Spine & Wellness
                                                Dr. Jeff Bowers
                                  Informed Consent to Chiropractic Care & X-ray

                                             ** Please Read & Sign**

I, have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about
its content, and signing below I agree to the above named procedures. I intend this form to cover the entire
course of treatment for my present and future conditions.

I authorize the performance of the diagnostic x-ray examination of myself which Dr. Jeff Bowers may consider
necessary or advisable in the course of my examination and treatment.

This is to certify that to the best of my knowledge, I am not pregnant, and Dr. Jeff Bowers has permission to
perform diagnostic x-ray examination. I have been advised that certain x-ray examinations, particularly those
involving the pelvis, can be hazardous to an unborn child.

To be completed by the patient:                        To be completed by the patient’s representative e.g., if the
                                                       patient is a minor or physically or legally incapacitated

________________________________                ______________________________________
PRINT NAME                                             PRINT NAME OF PATIENT’S REPRESENTATIVE

________________________________                ______________________________________

_________________                               _______________________________________
DATE                                                   RELATIONSHIP OR AUTHORITY OF PATIENT’S REP.

*** Office***

________________________________                _____________________________________
Witness Print Name                                     Witness Signature/Date
                                          Kirkland Spine & Wellness
                                                Dr. Jeff Bowers
                                                Financial Policy

Please present your insurance card today. We will phone your insurance company to verify that you have
Chiropractic/Massage coverage. If you do, our office will submit claims on your behalf to your insurance
company. Please note that healthcare and accident insurance policies are an arrangement between an
insurance carrier and the subscriber/patient, and said patient is personally responsible for services rendered.
Our office will prepare any necessary reports and forms to assist in making collection from the insurance
company. However please be aware that sometimes insurance companies deny claims for various reasons. We
will resubmit such claims if the denial is based in an error on our part, if however claims are denied for any
other reason, we will then bill the patient directly and let them collect reimbursement from their insurance
company. If your insurance plan requires a PCP referral it is YOUR responsibility to provide this office with
written authorization from your PCP. If your insurance plan requires a calendar year deductible and it has not
been satisfied at the time of service, payment will be collected from the patient on the day services are
rendered, unless you have made other prior arrangements with the billing coordinator.
We strongly urge you to verify your own benefits as the contact between you and your insurance and
whatever they tell you is binding.

Fee’s are expected at the time services are rendered unless special arrangements have been made in advance.
Please ask the front desk for a copy of our current price list.

You need to report your accident to your employer, bring in any necessary documentation of the accident and
insurance information (if applicable). Complete and sign accident report and the L&I long form. Until the claim
is approved/denied you may be required to pay acquired fees on a cash basis.

You will need to provide our office with following information:
Accident Report, Police Report, your Car Insurance Information, the other party’s information, your attorney
information, and the other party’s attorney information (if applicable). Until all of the necessary information is
provided you may be required to pay acquired fees on a cash basis. Patients with Personal Injury Protection
(PIP) are not required to pay acquired fees. Its is our office policy that you obtain an attorney if you do not
have PIP, If you do not have an attorney please let us know so that we can further assist you in obtaining legal

                                        284 Central Way, Kirkland WA 98033
                                               Phone: 425-605-8508
                                         Kirkland Spine & Wellness
                                               Dr. Jeff Bowers
                                               Financial Policy

Neither Kirkland Spine & Wellness nor any of the Doctors, Therapists or staff can enter into any dispute with
any insurance company and so it is your obligation and full responsibility to see that your bill is paid.

** Please Read and Sign**
I understand and agree that health/accident insurance policies are an arrangement between an insurance
carrier and myself. I understand and agree that all services rendered to me and charged are my personal
responsibility for timely payment. I understand that if I suspend to terminate my care/terminate my
care/treatment, any fee for professional services rendered to me will be immediately due and payable.

Patient Signature: ________________________________ Date: _________________

Print Name: ____________________________________

*If a minor*

Guardian Signature: _______________________________ Date: _________________

Print Name: _________________________________ Relationship: _______________

                                       284 Central Way, Kirkland WA 98033
                                              Phone: 425-605-8508
                                            Kirkland Spine & Wellness
                                                  Dr. Jeff Bowers
                                        Notice of Privacy Practices (HIPPA)

This notice describes how health information about you may be used and disclosed and how you can get access to this
information. We have the following duties regarding the maintenance, use and disclosure of your health records:

           (1) Kirkland Spine & Wellness is required by law to maintain the privacy of the protected
               health information in your records and to provide you with this Notice of our legal duties and
               privacy practices with respect to you protected health information.
           (2) Kirkland Spine & Wellness is required to abide by the terms of its Notice currently in effect.
           (3) Kirkland Spine & Wellness reserves the right to change the terms of this Notice at any time,
               making the new provisions effective for all health information and records that we have and
             continue to maintain. All changes in this Notice will be prominently displayed and available at
             out office.
There are a number of situations in which we may use of disclose to other persons or entities your
confidential health information. Certain uses and disclosures will require you to sign an acknowledgment
that you received this Notice of Privacy Practices. These include treatment, payment and health care
operations. Any use of disclosures of your protected health information required for anything other than
treatment, payment or health care operations requires you to sign an Authorization. Certain disclosures
that are required by law, or under emergency circumstances, may be made without your Acknowledgment
or Authorization. Under any circumstances, we will use or disclose only the minimum amount of
information necessary form you medical records to accomplish the intended purpose of the disclosure.

We will attempt in good faith to obtain your signed Acknowledgment that you received this Notice to use
and disclose your confidential medical information for the following purposes. These examples are not
meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office
you have provided Consent.

TREATMENT: We will use your healthcare information to make decisions about the provision, coordination
or management of your healthcare, including analyzing or diagnosing your condition and determining the
appropriate treatment for that condition. It may also be necessary to share your health information with
another health care provider whom we need to consult with respect to your care. You should be aware that
we utilize an “open adjusting room” in which several people may be adjusted at the same time and in close
proximity. We will try to speak quietly to you in a manner reasonable calculated to avoid disclosing you
health information to others; however, complete privacy may not be possible in this setting. If you would
prefer to be adjusted in a private room, please let us know and we will do our best to out accommodate
your wishes.

PAYMENT: We may need to use or disclose information in your health record to obtain reimbursement
from you, from your health insurance carrier, or from another insurer for our services rendered to you. This
may include determinations of eligibility or coverage under the appropriate health plan pre-certified and
pre-authorization of services or review of services for the purpose of reimbursement. This information may
also be used for billing, claims management and collection purposes, and related healthcare data
processing through our systems.
                                             Kirkland Spine & Wellness
                                                   Dr. Jeff Bowers
                                         Notice of Privacy Practices (HIPPA)

OPERATIONS: Your healthcare records may be used in our business planning and development operations,
including improvements in our methods of operation, and general administrative functions. We may also
use the information in our overall compliance planning, healthcare review activities, and arranging for legal
and auditing functions.

There are certain circumstances under which we may use or disclose your health information without first
obtaining your Acknowledgment or Authorization. Those circumstances generally involve public health and
oversight activities, law-enforcement activities, judicial and administrative proceedings, and in the event of
death. Specifically, we may be required to report to certain agency information concerning certain
communicable diseases, sexually transmitted diseases or HIV/AIDS status. We may also be required to
report instances of suspected or documented abuse, neglect or domestic violence. We are required to
report to appropriate agencies and law–enforcement officials information that you or another person is in
immediate threat of danger to health or safety as a result of violent activity. We must also provide health
information when ordered by a court of law to do so. We may contact you from time to time to provide
appointment reminders or information about treatment alternatives or other health related benefits and
services that may be of interest to you.

Change of Ownership: In the event Kirkland Spine & Wellness is sold or merged with another organization, your health
information/record will become the property of the new owner.

Others Involved in Your Healthcare: Unless you object, we may disclose to a member of you family, a
relative, a close friend or any other person you identify, your protected health information that directly
relates to that person’s involvement in your health care. If you are unable to agree or object to such a
disclosure, we may disclose such information as necessary if we determine that it is in your best interest
based on our professional judgment. We may use or disclose protected health information to an authorized
public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or
other individuals involved in healthcare.

Communication Barriers and Emergencies: We may use and disclose your protected health information if we attempt to
obtain consent from you but are unable to do so because of substantial communication
barriers and we determine, using professional judgment, that you intend to consent to use or disclose
under the circumstances. We may use or disclose your protected health information in an emergency
treatment situation. If this happens, we will try to obtain your consent as soon as reasonably practicable
after delivery of treatment. If we are required by law or as a matter of necessity to treat you, and we have
attempted to obtain your consent but have been unable to obtain your consent, we may still use or disclose
your protected health information to treat you.
Except as indicated above, your health information will not be used or disclosed to any other person or
entity without your specific Authorization, which may be revoked at any time. In particular, except to the
extent disclosure has been made to governmental entities required by law to maintain the confidentiality of
the information. This information will not be further disclosed to any other person or entity with respect to
information concerning mental-health, drug and alcohol abuse, HIV/AIDS or sexually transmitted diseases
that may be contained in your health records. We likewise will not disclose your health-record information
to an employer for purposes of making employment decisions, to a liability insurer or attorney as a result of
injuries sustained in an automobile accident, or to educational authorities, without your written
                                            Kirkland Spine & Wellness
                                                  Dr. Jeff Bowers
                                        Notice of Privacy Practices (HIPPA)

You have certain rights regarding your health record information, as follows:

          (1) You may request that we restrict the uses and disclosures of your health record information
          for treatment, payment and operations, or restrictions involving your care or payment related
          to your care. We are not required to agree to the restrictions; however, if we agree, we will
          comply with it, except with regard to emergencies, disclosure without restriction.
          (2) You have a right to request receipt of confidential communications of your medical
          information by an alternative means or at an alternative location. If you require such and
          accommodation, you may be charged a fee for the accommodation and will be required to
          specify the alternative address or method of contact and how payment will be handled.
          (3) You have the right to inspect, copy and request amendments to your health records. Access to
          your health records will not include psychotherapy notes contained in them, or information
          compiled in anticipation of or for use in civil, criminal or administrative action or proceeding to
          which your access is restricted by law. We will charge a reasonable fee for providing a copy of
          your health records, or a summary of those records, at your request, which includes the cost
          of copying, postage, and preparation or an explanation or summary of the information.
          (4) All request for inspection, copying and /or amending information in your health records, and
          all request related to your rights under this Notice, must be made in writing and addressed to
          the Privacy Officers at our address. We will respond to your request in a timely fashion.
          (5) You have a limited right to receive an accounting of all disclosures we make to other persons or
          entities of your health information. Except for disclosures required for treatment, payment
          and healthcare operation, disclosures that require an Authorization, disclosure incidental to
          another permissible use or disclosure, and otherwise as allowed by law. We will not charge
          you for the first accounting in any twelve-month period; however we will charge you a
          reasonable fee for each subsequent request for accounting within the same twelve-month
          (6) If this Notice was initially provided to you electronically, you have the right to obtain a paper
          copy of this notice and to take one home with you if you wish.

You may file a written complaint to us or to the Secretary of Health and Human Services if you believe that
your privacy rights with respect to confidential information in tour health records have been violated. All
complaint must be in writing and must be addressed to the Privacy Officer (in the case of complaints to us)
or to the person designated by the U.S. Department of Health and Human Services if we cannot resolve you
concerns. You will not be retaliated against for filling such a complaint. More information is available about
complaints at the government’s web site, http://www.hhw.gov/ocr/hipaa.

If you have any questions about any part of this notice, or if you want more information about your privacy
rights, please contact Dr. Jeffry D. Bowers by calling 425-605-8508.
If Dr. Bowers is not available, you may make an appointment for a personal conference in person
or by telephone within 2 working days. If you are not satisfied with the manner is which this office handles
you complaint, you may submit a formal complaint to:

DHHS, Office of Civil Rights
200 Independence Avenue, SW
Room 509F HHH Building
Washington DC, 20201
                                           Kirkland Spine & Wellness
                                                 Dr. Jeff Bowers
                                       Notice of Privacy Practices (HIPPA)

This notice is effective as of ____________/___________/__________

I have read the Privacy Notice and understand my rights in contained in the notice.

By way of my signature, I Kirkland Wellness & Spine with my Authorization and consent to use and
disclose my protected health care information for the purposes of treatment, payment and healthcare
operations as described in the Privacy Notice.

Patient’s Name (print)

_____________________________________                       ___________________
Patient’s Signature                                                Date

** To be signed by office staff**

_____________________________________                       ___________________
Authorized Facility Signature                                      Date
                                              Kirkland Spine & Wellness
                                                    Dr. Jeff Bowers
                                                 Terms of Acceptance

When a patient seeks chiropractic care and we accept a patient for such care, it is essential for both to be working
towards the same objective.

Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will
be used to attain it. This will prevent any confusion or disappointment.

Adjustment; An adjustment is the specific application of forces to facilitate the body’s correction of vertebral
Subluxation. Our chiropractic method of correction is by specific adjustments of the spine.

Health; A state of optimal physical, mental and social well being, not merely the absence of disease or infirmity.

Vertebral Subluxation; A misalignment of one or more of the 24 vertebra in the spinal column, which cause alteration of
nerve function and interference to the transmission of mental impulse, resulting in a lessening of the body’s innate ability
to express its maximum health potential.

We do not offer to diagnose or treat any disease or condition other than vertebral Subluxation.
However, if during the course of chiropractic spinal examination, we encounter non-chiropractic or unusual findings, we
will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the
services of another health care provider.

Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment
prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body’s
innate wisdom. Our only method is specific adjusting to correct vertebral subluxations.

I, __________________________ have read and fully understand the above statements.
                   (print name)
All questions regarding the doctor’s objectives pertaining to my care in this office have been answered to my complete
satisfaction. I therefore accept chiropractic care on this basis.

___________________________________                          _______________________
              (signature)                                                                    (date)

Consent to evaluate and adjust a minor.

I, ______________________ being the parent or legal guardian of ___________________
Have read and fully understand the above terms of acceptance and hereby grant permission for my child to receive
chiropractic care.

                                           284 Central Way , Kirkland, WA 98033
                                                  Phone: 425-605-8508

Shared By:
yan tingting yan tingting