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AMP Sports Med & Recovery | 30332 Esperanza | Rancho Santa Margarita, CA. 92688
O: 949-264-6440 | F: 949-264-6928 |
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I certify that I'm the patient or legal guardian listed above. I have read / understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health / accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care for treatment.
Signature
Date:
INFORMED CONSENT FOR CHIROPRACTIC TREATMENT AND CARE
To the patient (or their parent, legal guardian, court appointed conservator, or agent): Please read this entire form prior to signing it. It is important that you understand the information contained in here. Please ask any questions prior to signing this form if you are unclear about anything contained in in this form.
There are a number of procedures used by a Doctor of Chiropractic affiliated with AMP Sports Med, Inc., or a staff member under the Doctor’s supervision (collectively “AMP”) that may be used on you either in person or a telehealth virtual appointment. A physical examination will be performed to obtain a baseline level of functioning as well to determine an appropriate course of treatment and associated recommendations. The physical examination may include posture checks, range of motion testing, muscle strength testing, various neurological and orthopedic testing, and other testing. Radiology is the use of x-rays on the human body and is used to gain an inside perspective of the human body that cannot be obtained from a physical examination. Determined treatment may include chiropractic adjustments, physical therapy (such as ultrasound, interferential therapy, massage therapy, exercise recommendations, AMP therapy and recovery, etc.). Additionally, we may refer you to other doctors as necessary, and their treatment should involve the same informed consent with the disclosure of risks and benefits as is being done here.
AMP Therapy And Recovery
Advanced Myofascial Percussion (AMP) Therapy and Recovery System is a unique and innovative associated care technology that facilitates oxygenated blood and quickly restores range of motion. The AMP System breaks down adhering scar tissue and reduces neurotransmitter pain factors. The functional movement patterns during the AMP System restores neuromuscular firing, while allowing the body to heal at a faster rate. The Percussion technology removes lactic acid and metabolizes alkalinity into neuromuscular tissues. The Recovery System modalities such as Cryotherapy, Normatec, Game Ready, and Cellumma Laser are designed to specifically aid in recovery and help prepare the body to handle levels of physical stress place upon it by high level competition and performance demands. AMP systems, which are non-chiropractic, maybe are administered by trained staff members, including clinical student participation in both treatment and examination, under the Doctor’s supervision.
Chiropractic Adjustments
This treatment is rendered by the Doctor. The treatment may also be administered by clinical students (both the adjustment/treatment and the examination) at all times under the Doctor’s supervision. Chiropractic adjustments, which are purposely intentioned movements of bones with the desired effect being to remove interference to nerves, which then allows your body to use its innate ability to heal itself. Chiropractic adjustments also have the desirable effect of enabling muscles, tendons, and ligaments to properly function and heal, and also allows blood flow to properly occur. Chiropractic adjustments can be made by either the use of hands or mechanical instruments to any bone or joint in the body including both spinal and extremity bones. You may or may not hear an audible sound, which is air being released from the joint space as bones are moved into their proper positions. Also, physical therapy procedures including AMP therapy may be recommended and used at the Doctor’s discretion.
Potential Benefits of Chiropractic and Associated Care
The majority of our patients tend to achieve good to excellent improvement in their physical well being. Improvement can be measured in many different ways, including reduction in pain, increased range of motion, less stiffness, increased athletic performance etc. However, results vary from person to person, as each person has different pre-existing conditions, physical fitness levels, different ages and occupations (with different types of physical stress). Your situation is unique, and no guarantees are given. You will have to determine what results you get for yourself and report them to your Doctor.
Material Risks Inherent with Chiropractic Adjustments and Other Associated Care
As with any healthcare procedure, there are certain complications which may arise when chiropractic adjustments and other care/procedures are performed. These complications include but are not limited to fractures of bones, disc injuries, dislocations, muscle strains, cervical myelopathy, strokes, radiation exposure, costovertebral strains and separations, and burns. Some patients feel some stiffness and/or soreness following the first few days of treatment. The physical exam can temporarily worsen symptoms, but is a necessary part of chiropractic care. The Doctor will make every reasonable effort during the examination to screen for contraindications to care, but remember it is your responsibility to inform the Doctor of any conditions that would not otherwise come to their attention.
Probability of Risks Occurring
Fractures are rare occurrences and generally result from some underlying weakness of bone. Even though a competent history and examination (which may include radiography) will be performed, it is still possible for some weaknesses of bone to be undetected. Extremely rare are strokes from vertebral artery dissection caused by chiropractic manipulation of the neck and has been the subject of ongoing medical research and debate. The most current research on the topic is inconclusive as to a specific incident of this complication occurring. If there is a causal relationship at all it is extremely rare and remote. Unfortunately, there is no recognized screening procedure to identify patients with neck pain who are at risk of arterial stroke. Although discs are generally helped with chiropractic care, they can be worsened even to the point of requiring surgical care (although this rarely occurs). Physical therapy can sometimes burn skin by irritating it, although this is unlikely to occur.
Consequences of Not Obtaining Chiropractic Care
Not obtaining chiropractic care or other related treatment may allow formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Also the failure to obtain treatment may result in your body not functioning at its best, and other benefits from treatment such as reducing pain, obtaining peak athletic performance, etc. Over time this process may complicate treatment making it more difficult, requiring more time (and money), and less effective when chiropractic care or other related treatment is sought later. Not obtaining chiropractic care following trauma such as whiplash or other effects of automobile accidents may cause injured muscles, tendons, and ligaments to heal improperly and be significantly weaker and more prone to re-injury as compared to receiving proper care.
Alternatives to Chiropractic Care
Other treatment options for your condition may include rest, acupuncture, physical therapy, medical care, medications (both over the counter and prescribed), hospitalization, and surgery, and others. If you choose to use other treatment options, you should discuss the risks and benefits with your medical doctor or other provider.
DO NOT SIGN THIS FORM UNTIL YOU HAVE READ AND UNDERSTAND THIS FORM. UPON DOING SO, PLEASE COMPLETE THE INFORMATION AND SIGN THIS FORM.
I have read, or had read to me the above consent and have discussed it with Doctor . By signing below I state that I have weighed the risk involved in undergoing treatment and have decided it is in my best interest to undergo the treatment recommended. Having been informed of the risk I hereby give my consent to treatment.
Patient's Printed Name:
Date:
Patient's Signature:
CONSENT TO TREATMENT (MINOR)
I hereby request and authorize Doctor to perform diagnostic tests and render chiropractic adjustments and other treatment to my minor son/daughter: <CHILDFIRSTNAME> <CHILDLASTNAME>. This authorization also extends to all other doctors and office staff members and is intended to include radiographic examination at the Doctor’s discretion.
As of this date, I have the legal right to select and authorize health care services for the minor child named above. (If applicable) Under the terms and conditions of my divorce, separation or other legal authorization, the consent of a spouse/former spouse or other parent is not required. If my authority to so select and authorize this care should be revoked or modified in any way, I will immediately notify AMP.
Patient's Printed Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
Date:
Signature of Parent, Guardian, Conservator or Agent:
CONSENT TO TREATMENT (MINOR)
I hereby request and authorize Doctor to perform diagnostic tests and render chiropractic adjustments and other treatment to my minor son/daughter: <CHILDFIRSTNAME> <CHILDLASTNAME>. This authorization also extends to all other doctors and office staff members and is intended to include radiographic examination at the Doctor’s discretion.
As of this date, I have the legal right to select and authorize health care services for the minor child named above. (If applicable) Under the terms and conditions of my divorce, separation or other legal authorization, the consent of a spouse/former spouse or other parent is not required. If my authority to so select and authorize this care should be revoked or modified in any way, I will immediately notify AMP.
Patient's Printed Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
Date:
Signature of Parent, Guardian, Conservator or Agent:
CONSENT TO TREATMENT (MINOR)
I hereby request and authorize Doctor to perform diagnostic tests and render chiropractic adjustments and other treatment to my minor son/daughter: <CHILDFIRSTNAME> <CHILDLASTNAME>. This authorization also extends to all other doctors and office staff members and is intended to include radiographic examination at the Doctor’s discretion.
As of this date, I have the legal right to select and authorize health care services for the minor child named above. (If applicable) Under the terms and conditions of my divorce, separation or other legal authorization, the consent of a spouse/former spouse or other parent is not required. If my authority to so select and authorize this care should be revoked or modified in any way, I will immediately notify AMP.
Patient's Printed Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
Date:
Signature of Parent, Guardian, Conservator or Agent:
CONSENT TO TREATMENT (MINOR)
I hereby request and authorize Doctor to perform diagnostic tests and render chiropractic adjustments and other treatment to my minor son/daughter: <CHILDFIRSTNAME> <CHILDLASTNAME>. This authorization also extends to all other doctors and office staff members and is intended to include radiographic examination at the Doctor’s discretion.
As of this date, I have the legal right to select and authorize health care services for the minor child named above. (If applicable) Under the terms and conditions of my divorce, separation or other legal authorization, the consent of a spouse/former spouse or other parent is not required. If my authority to so select and authorize this care should be revoked or modified in any way, I will immediately notify AMP.
Patient's Printed Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
Date:
Signature of Parent, Guardian, Conservator or Agent:
CONSENT TO TREATMENT (MINOR)
I hereby request and authorize Doctor to perform diagnostic tests and render chiropractic adjustments and other treatment to my minor son/daughter: <CHILDFIRSTNAME> <CHILDLASTNAME>. This authorization also extends to all other doctors and office staff members and is intended to include radiographic examination at the Doctor’s discretion.
As of this date, I have the legal right to select and authorize health care services for the minor child named above. (If applicable) Under the terms and conditions of my divorce, separation or other legal authorization, the consent of a spouse/former spouse or other parent is not required. If my authority to so select and authorize this care should be revoked or modified in any way, I will immediately notify AMP.
Patient's Printed Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
Date:
Signature of Parent, Guardian, Conservator or Agent:
CONSENT TO TREATMENT (MINOR)
I hereby request and authorize Doctor to perform diagnostic tests and render chiropractic adjustments and other treatment to my minor son/daughter: <CHILDFIRSTNAME> <CHILDLASTNAME>. This authorization also extends to all other doctors and office staff members and is intended to include radiographic examination at the Doctor’s discretion.
As of this date, I have the legal right to select and authorize health care services for the minor child named above. (If applicable) Under the terms and conditions of my divorce, separation or other legal authorization, the consent of a spouse/former spouse or other parent is not required. If my authority to so select and authorize this care should be revoked or modified in any way, I will immediately notify AMP.
Patient's Printed Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
Date:
Signature of Parent, Guardian, Conservator or Agent:
CONSENT TO TREATMENT (MINOR)
I hereby request and authorize Doctor to perform diagnostic tests and render chiropractic adjustments and other treatment to my minor son/daughter: <CHILDFIRSTNAME> <CHILDLASTNAME>. This authorization also extends to all other doctors and office staff members and is intended to include radiographic examination at the Doctor’s discretion.
As of this date, I have the legal right to select and authorize health care services for the minor child named above. (If applicable) Under the terms and conditions of my divorce, separation or other legal authorization, the consent of a spouse/former spouse or other parent is not required. If my authority to so select and authorize this care should be revoked or modified in any way, I will immediately notify AMP.
Patient's Printed Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
Date:
Signature of Parent, Guardian, Conservator or Agent:
CONSENT TO TREATMENT (MINOR)
I hereby request and authorize Doctor to perform diagnostic tests and render chiropractic adjustments and other treatment to my minor son/daughter: <CHILDFIRSTNAME> <CHILDLASTNAME>. This authorization also extends to all other doctors and office staff members and is intended to include radiographic examination at the Doctor’s discretion.
As of this date, I have the legal right to select and authorize health care services for the minor child named above. (If applicable) Under the terms and conditions of my divorce, separation or other legal authorization, the consent of a spouse/former spouse or other parent is not required. If my authority to so select and authorize this care should be revoked or modified in any way, I will immediately notify AMP.
Patient's Printed Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
Date:
Signature of Parent, Guardian, Conservator or Agent:
CONSENT TO TREATMENT (MINOR)
I hereby request and authorize Doctor to perform diagnostic tests and render chiropractic adjustments and other treatment to my minor son/daughter: <CHILDFIRSTNAME> <CHILDLASTNAME>. This authorization also extends to all other doctors and office staff members and is intended to include radiographic examination at the Doctor’s discretion.
As of this date, I have the legal right to select and authorize health care services for the minor child named above. (If applicable) Under the terms and conditions of my divorce, separation or other legal authorization, the consent of a spouse/former spouse or other parent is not required. If my authority to so select and authorize this care should be revoked or modified in any way, I will immediately notify AMP.
Patient's Printed Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
Date:
Signature of Parent, Guardian, Conservator or Agent:
CONSENT TO TREATMENT (MINOR)
I hereby request and authorize Doctor to perform diagnostic tests and render chiropractic adjustments and other treatment to my minor son/daughter: <CHILDFIRSTNAME> <CHILDLASTNAME>. This authorization also extends to all other doctors and office staff members and is intended to include radiographic examination at the Doctor’s discretion.
As of this date, I have the legal right to select and authorize health care services for the minor child named above. (If applicable) Under the terms and conditions of my divorce, separation or other legal authorization, the consent of a spouse/former spouse or other parent is not required. If my authority to so select and authorize this care should be revoked or modified in any way, I will immediately notify AMP.
Patient's Printed Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
Date:
Signature of Parent, Guardian, Conservator or Agent:
I certify that I’m the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to . I authorize this office, AMP Sports Med & Recovery, and its staff to examine and treat my condition. I hereby authorize to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I’m responsible for timely payment of such services. I understand and agree that health/accident insurance policies are in arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care for treatment.
Signature of Patient :
Signature of Legal Guardian :
Date Signed:
SUPPLEMENTAL INFORMED CONSENT
Thank you for your continued trust in our services. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as “Coronavirus” at any time or in any place. Be assured that we have always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit the transmission of all diseases in our facility and continue to do so.
Despite our careful attention to sterilization and disinfection, there is still a chance that you could be exposed to an illness in our facility, just as you might in your grocery store or favorite restaurant. Social distancing nationwide has reduced the transmission of the Coronavirus. Although we have taken measures to provide social distancing in our facility, due to the nature of the services we provide, it is not possible to maintain social distancing between patients, doctors, therapists, specialists, and staff at all times.
I will not hold AMP Sports Med & Recovery, AMP Tustin, the staff, and patients accountable or pursue a lawsuit if I contract COVID-19, in or around AMP Sports Med & Recovery and AMP Tustin.
Do you accept the risk and consent to our services?
YES
NO
PRINT: Patient / Parent
SIGNATURE: Patient / Parent
Date:
AMP Sports Med, Inc. ®
HIPPA Privacy Notice
Insurance Letter
* Please fill out this form whether or not you will be using insurance for your appointments.
* All New Patients are required to fill out credit card information to hold the new patient appointment.
This letter is to inform you of the possible reimbursement options your health insurance company may choose once your claim for treatment in our office has been processed.
If your insurance carrier is out of network, they will most likely mail any payment due to AMP SPORTS MED & RECOVERY to you directly with the subscriber's name on the check. They cannot send funds to a provider out of state due to inter-state law, therefore they will make the payment to the policy holder directly with an explanation of benefits included. Our office will be notified that you have been sent the funds due to AMP SPORTS MED & RECOVERY for your dates of service as well. Once you receive the check(s), you will be required to bring or mail a personal check to our office made payable to AMP SPORTS MED & RECOVERY at the following address:
AMP SPORTS MED & RECOVERY
30332 Esperanza
Rancho Santa Margarita, CA 92688
If you have already deposited the check(s) into your account, you can pay our office with a credit card but please note there will be a 3.5% processing fee applied.
Please note that the only reason your insurance company would send you a check with an explanation of benefits would be for payment of treatment rendered to you by a provider. The insurance company will NOT pay you to see your doctor or reimburse your co-pays.
Please contact me at the email address below with any questions or concerns you may have. Failure to sign the below document will result in your insurance being rejected and you will be required to pay the cash rates. Thank you for your understanding and cooperation
PLEASE READ EACH BULLET POINT
• Insurance checks that I receive will be promptly brought into the office. Inability to do so within 14 days of receipt of insurance checks authorizes AMP SPORTS MED to charge the credit card on file for the unpaid charges on my account.
• If my insurance company does not make payment to AMP SPORTS MED for services rendered, I will become personally responsible for the charges. I will have 14 days to clear my account by calling my insurance after being notified by this office. If the account is not cleared within 14 days, I hereby authorize AMP SPORTS MED to charge any outstanding amount to my credit card.
• I understand that if my account has not been settled within 14 days, a weekly interest rate of 3% will be added to my account until the balance is paid in full.
I authorize the above named business to charge the credit card indicated in this authorization form for services rendered. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company when charged for services rendered.
I understand and agree to all of the information written above.
PATIENTS NAME:
CARDHOLDERS SIGNATURE:
DATE:
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 IT CAREFULLY.
AMP Sports Med, Inc. ® is required, by law, to maintain the privacy and confidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information.
Disclosure of Your Health Care Information Treatment: We may disclose your healthcare information to other healthcare professionals within our practice, such as physical therapist, certified trainers, certified massage therapist and the like, for the purpose of treatment, payment, or healthcare operations. Example: "On occasion, it may be necessary to seek consultation regarding your condition from other healthcare providers." It is our policy to provide a substitute health care provider, authorized by AMP Sports Med, Inc., without advanced notice, in the event of your primary healthcare providers absence due to vacation, sickness, or other emergency.
Payment: We may disclose your health information to your insurance provider for the purpose of payment or healthcare operations. Example: "Asa courtesy to our patients we will submit an itemized billing statement to your insurance carrier for the purpose of payment to AMP Sports Med, Inc. for healthcare services rendered. If you pay for your healthcare services personally, we will, as a courtesy, provide an itemized billing to your insurance carrier for the purpose of reimbursement to you. The billing statement contains medical information, including diagnosis, date of injury or condition, and codes which describe the healthcare services received."
Workers' Compensation: We may disclose your health information as necessary to comply with State Workers' Compensation Laws.
Emergencies: We may disclose your health information to notify or assist in notifying a family member, or another person responsible for your care about your medical condition or in the event of an emergency or of your death.
Public Health: As required by law, we may disclose your health information to public health authorities for purposes related to preventing or controlling disease, injury or disability, reporting child abuse or neglect, reporting domestic violence, reporting to the Food and Drug Administration problems with products and reactions to medications, and reporting disease or infection exposure.
Judicial and Administrative Proceedings: We may disclose your health information in the course of any administrative or judicial proceeding.
Law Enforcement: We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena, and other law enforcement purposes.
Deceased Persons: We may disclose your health information to coroners or medical examiners.
Organ Donation: We may disclose your health information to organizations involved in procuring, banking, or transplanting organs and tissues.
Research: We may disclose your health information to researchers conducting research that has AMP Sports Med, Inc. ® been approved by an Institutional Review Board.
Public Safety: It may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public.
Specialized Government Agencies: We may disclose your health information for military, national security, prisoner and government benefits purposes.
Change of Ownership in the event that Amp Sports Med, Inc. is sold or merged with another organization your health information/record will become the property of the new owner
AMP Sports Med, Inc.® 30332 Esperanza, Rancho Santa Margarita, CA. 92688
Your Health Information Rights:
- You have the right to request restrictions on certain uses and disclosures of your health information. Please be advised, however, that AMP Sports Med, Inc. is not required to agree to the restriction that you requested.
- You have the right to have your health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication or delivery, upon your request.
- You have the right to inspect and copy your health information.
- You have a right to request that AMP Sports Med, Inc. amend your protected health information. Please be advised, however, that AMP Sports Med, Inc. is not required to agree to amend your protected health information. If your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s) and information about how you can disagree with the denial.
- You have a right to receive an accounting of disclosures of your protected health information made by AMP Sports Med, Inc. You have a right to a paper copy of this Notice of Privacy Practices at any time upon request.
Changes to this Notice of Privacy Practices AMP Sports Med, Inc. reserves the right to amend this Notice of Privacy Practices at any time in the future and will make the new provisions effective for all information that it maintains. Until such amendment is made, AMP Sports Med, Inc. is required by law to comply with this Notice. AMP Sports Med, Inc.is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about your privacy rights, please contact the office, you may make an appointment for a personal conference in person or by telephone within 2 working days.
Complaints about your Privacy rights or how AMP Sports Med, Inc. has handled your health information should be directed to him by calling the office. If AMP Sports Med, Inc. 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 in which this office handles your complaint, you may submit a formal complaint to:
DHHS, Office of Civil Rights
200 Independence Avenue, S.W. Room 509F, HHH Building
Washington, D.C. 20201