HIPAA Consent & Office Policies

HIPAA 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.

If you have any questions about the above notice, please contact our Office at 425-641-7470

We are required by law to: 

• Maintain the privacy of protected health information 

• Give you the notice of your legal duties and privacy practices regarding health information about you 

• Follow the terms of our notice that is currently in effect

Described as follows are the ways we may use and disclose health information that identifies you ("Health Information"). Except for the following purposes, we will use and disclose health information only with your written permission. You may revoke such permissions at any time by writing to our practice's privacy officer.

We may use and disclose Health Information for your treatment and to provide you with treatment-related health care services. For example, we may disclose Health Information to doctors, nurses, technicians, or other personnel, including people outside our office, who are involved in your medical care and need the information to provide you with medical care.

We may use and disclose Health Information so that we or others may bill and receive payment from you, an insurance company, or a third party for treatment and services you receive. For example, we may give your health plan information so that they will pay for your treatment.

We may use and disclose Health Information for health care operation purposes. These uses and disclosures are necessary to make sure that all of our patients receive quality care to operate and manage our office. For example, we may use and disclose information to make sure the obstetric or gynecologic care you receive is of the highest quality. We also may share information with our entities that have a relationship with you (for example, your health plan) for their health care operation activities.

We may use and disclose Health Information to contact you and remind you that you have an appointment with us. We also may use and disclose Health Information to tell you about treatment alternatives or health related benefits and services that may be of interest to you.

When appropriate, we may share Health Information with a person who is involved in your medical care or payment for your care, such as your family or a close friend. We also may notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort.

Under certain circumstances, we may use and disclose Health Information for research. For example, a research project may involve comparing the health of patients who receive one treatment to those who receive another for the same condition. Before we use or disclose Health Information for research, the project will go through a special approval process. Even without special approval, we may permit researchers to look at records to help them identify patients who may be included in their research project or for other similar purposes.

As required by law. We will disclose Health Information when required to do so by international, federal, state, or local law.

Disclosure of Health Information:

We will disclose Health Information when necessary to prevent a serious threat to your health and safety or the public, or another person. Disclosure, however, will be made only to someone who may be able to help provide treatment.

We may disclose Health Information to our business associates that perform functions on our behalf or to provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than that as specified in our contract.

If you are an organ donor, we may use or release Health Information to organizations that handle organ procurement or other entities engaged in procurement; banking or transportation of organs, eyes, or tissues to facilitate organ, eye, or tissue donation, and transplantation.

If you are a member of the army forces, we may use or release Health Information as required by military command authorities. We also may release Health Information to the appropriate foreign military authority if you are a member of a foreign military.

We may release Health Information for worker's compensation or similar programs. These programs provide benefits for work-related injuries or illness.

We may disclose Health Information for public health activities. These activities generally include disclosure to prevent or control disease, injury, or disability; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; inform a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and report to the appropriate government authority if we believe a patient has been a victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required by law.

We may disclose Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

If you are involved in a lawsuit or dispute, we may disclose Health Information in response to a court or a court administrator order. We also may disclose Health Information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

We may release Health Information if asked by a law enforcement official if the information is needed: 

1) in response to a court order, subpoena, warrant, summons, or similar process; 

2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; 

3) about the victim of crime even if, under certain circumstances, we are unable to obtain the person's agreement; 

4) about a death we believe may be the result of criminal conduct; 

5) about criminal conduct on our premises and; 

6) in an emergency to report a crime to the location of the crime if victims, or the identity, description, or location of the person who committed the crime.

We may release Health Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release Health Information to funeral directors as necessary for their duties.

We may release Health Information to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state, or to conduct special investigations.

You have the following rights regarding Health Information we have about you: 

1) Right to Inspect and Copy, 

2) Right to Amend, 

3) Right to an Accounting of Disclosures, 

4) Right to Request Restrictions, 

5) Right to Request Confidential Communication, 

6) Right to a Paper Copy of This Notice.

We reserve the right to change this notice.

If you believe your privacy has been violated please notify our office immediately, you will not be penalized for filing a complaint.

Please provide ONLY the Last 4 Digits of your Social Security Number below:

6965 Coal Creek PKWY SE, Newcastle, WA, 98059

Phone: 425-641-7470 Fax: 425-373-9176

Informed Consent for Chiropractic Care

When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both of us to be working for the same objective. It is important that each patient understand both the objective(s) and the method(s) that will be used to attain this objective. This will prevent any confusion or disappointment. You have the right, as a patient, to be informed about the condition and the recommended care to be provided so that you make the decision whether or not to undergo chiropractic care after being advised of the known benefits, risks, and alternatives.

Chiropractic is a science, philosophy and art which concerns itself with the relationship between the spinal structure and the health of the nervous system. As chiropractors we understand that health is a state of optimal physical, mental, and social well-being, not merely the absence of disease or infirmity.

One disturbance to the nervous system is called a vertebral subluxation. This occurs when one or more of the 24 vertebra in the spinal column become misaligned and/or do not move properly. This causes an unhealthy change to nerve function and interference to the nervous system. This may result in pain and dysfunction or may be entirely asymptomatic.

Subluxations are corrected and/or reduced by a chiropractic adjustment. An adjustment is the specific application of force to correct and/or reduce vertebral subluxation. Our chiropractic method of correction is by specific adjustments to the spine. Adjustments are done by hand where the doctor will put pressure on the specific segment(s) of the spine to adjust the vertebrae into a better position.

If at the beginning or during the course of care we encounter a non-chiropractic or unusual findings, we will advise you of those findings and recommend some further testing or refer you out to another health care provider.

Chiropractic care has been proven to be very safe and effective. It is not unusual however, to be sore after your first few corrective adjustments. Although rare it is possible to suffer from other side effects; i.e. muscle spasms, stiffness, rib fracture, headache, dizziness and stroke.

All questions regarding the doctor's objective to my care in this office has been answered to my complete satisfaction. The benefits, risks and alternatives of chiropractic care have been explained to me to my satisfaction. I have read and fully understand the above statements and therefore accept chiropractic care on this basis.

Consent to evaluate and adjust a minor child

I, being the parent or legal guardian have read and fully understand the above Informed Consent and hereby grant permission for my child to receive chiropractic care. (Please enter parent or legal guardian full name below)

X-Ray Consent

This is to certify that to the best of my knowledge I am not pregnant and the above doctor and his/her associates have my permission to perform an x-ray evaluation. I have been advised that x-rays can be hazardous to an unborn child.

6965 Coal Creek PKWY SE, Newcastle, WA, 98059

Phone: 425-641-7470 Fax: 425-373-9176

Office Financial Policy

Thank you for trusting us to be your health care provider. We appreciate the opportunity to serve you. We are concerned about the ever-rising cost of health care and are dedicated to holding down costs to our patients. Our staff committed to your successful treatment and well-being. Please read the following financial policy and information carefully and sign at the bottom of the page prior to treatment. If you have any questions, please ask the receptionist for clarification.

1. You are responsible for payment of the services you receive in our office. Please understand that your medical insurance is a contact between you and your insurance company. You are ultimately responsible for any unpaid balance.

2. There are hundreds of insurance carriers and plans in place today. They can and do change, often yearly in some instances more frequently. It is your responsibility to know your plan benefits including co-pay amounts, deductibles and what are covered and non-covered services. We are here to practice chiropractic in the best interest of the health of our patients. Often times there is a conflict between what our doctors need to do to follow good chiropractic practices and what may be covered by your insurance carrier. You will be billed for non-covered benefit services. Common examples of these potentially non-covered services include physical therapy modalities, rehabilitation supplies, wellness care visits and massage. It is your responsibility to know whether your insurance plan covers (pays for) these services or not.

3. If you have insurance coverage, please give your current insurance identification card to our receptionist. We will gladly bill your insurance company directly with the appropriate charges and diagnosis codes provided by your chiropractic physician. Please do not ask us to change codes afterwards if your insurance carrier does not pay your services. We follow strict coding guidelines established by the American Medical Association as well as those established and covered by Federal and State Programs and Statutes.

4. Your deductible and co-payment are due at the time of your office visit. We accept payment in cash, check, vis, Mastercard, and American Express. Your co-insurance balance may not exceed $100.00 at any time or care may be terminated. We will provide a receipt for all payments. Please retain this receipt for your records.

5. If your carrier has not paid a claim in sixty (60) days of submission, you agree to take an active part in the recovery of your claim. If your insurance carrier has not paid within ninety (90) days of submission, you accept responsibility for payment in full of any outstanding balance and authorize us to use your credit card to collect full payment. Should patient default in the payment of any amounts due Chiropractic Wellness Center and/or assigns, patient shall pay all actual and reasonable costs of collections and/or suit, including reasonable attorney's fees and disbursements, plus pre-judgement interest at 12% per annum or delinquent payments. Jurisdiction and venue shall be in the King County District Court at Issaquah, Washington. Patient agrees to pay the sum of $20.00 as a service fee for each check returned for insufficient funds.

6. If you do not have insurance coverage all payments are expected at the time of service or by an authorized payment plan. Your personal balance may not exceed $100.00 at any time or care may be terminated. Our payment plans take into consider an affordable part of your family budget.

7. I authorize the staff at Chiropractic Wellness Center at Newcastle to perform any necessary services needed during diagnosis and treatment. I also authorize the provider of managed care organization to release any information required to process insurance claims. I understand that the above information and acknowledge that it is my responsibility to inform this office of any changes in my medical status.

6965 Coal Creek PKWY SE, Newcastle, WA, 98059

Phone: 425-641-7470 Fax: 425-373-9176

Massage Policy

The massage therapists at Chiropractic Wellness Centers are committed to serving you with the best care possible. As a courtesy to you, we would like to inform you of our policies regarding massage therapy. You are required to leave a current credit card on file for no show fees and/ or patient balance. Updated 5/16/2024

1. Massage therapy is not a substitute for medical examination/diagnosis by a primary care provider. The massage therapist does not diagnose illness or disease, prescribe drug therapy or perform chiropractic manipulations of the spine. It is recommended that you see a physician for any physical ailment that you may have.
2. To receive the maximum benefit for your treatment it is necessary that you comply with the prescribed or recommended treatment plan.
3. For the therapeutic massage to be safe and effective, please inform the Therapist of any patient medication, anti-inflammatory or other drugs that you may be taking.
4. The safest condition for the massage recipient is to be drug and alcohol free for at least 8 hours prior to the appointment, so the sensation is not compromised. The client shall keep the therapist informed of any changes in your healthcare status and treatment.
5. Please drink plenty of water before and after your massage. Failure to stay hydrated may result in nausea and other unpleasant symptoms.
6. Due to the intimate nature of the massage/bodywork, personal cleanliness is necessary.
7. Please be on time for your appointment. Arrive a few minutes early to use the restroom and relax. If you are more than 15 minutes late (this includes the time it would take to check in and be on the table) you will forfeit your massage and you will be charged a $90.00 no show fee.
8. We will try to give appointment reminder calls/texts or emails, however, it is ultimately your responsibility to keep your scheduled appointment.
9. If you need to cancel your appointment, please call at least 48 hours in advance. Missed appointments or those cancelled less than 48 hours in advance will be subject to a late cancellation fee of $90.00.
10. Please do not bring minor children to your massage appointment, we are not equipped with staff to watch your child while you are in session with the therapist.
11. You are ultimately responsible for all charges for treatment whether your insurance company reimburses or not.

We hope that this sheet presents our policies in a clear and useful manner. If you have any questions, please do not hesitate to ask any of the massage therapists or the front desk.

I have read and agree to abide by these policies.

6965 Coal Creek PKWY SE, Newcastle, WA, 98059

Phone: 425-641-7470 Fax: 425-373-9176