Intake Form
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Informed Consent

Every type of health care is associated with some risk of a potential problem. This includes chiropractic 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 the moving of bones with the clinician’s hands or with the use of a device. Frequently, adjustments create a “popping” or “clicking” sound/sensation in the areas being treated.

In this office, we use trained assistants who may assist the clinician with portions of your consultation, examination, x-ray taking, physical  therapy application, traction, massage therapy, exercise instruction, etc. On the occasion when your clinician is unavailable, your care may be handled by another clinician or trained assistant.

Coronavirus: With the ongoing pandemic, we require patients to inform us if they currently have a fever, have had one in the past 14 days, have been in contact with a person who is experiencing symptoms (fever, shortness of breath, fever, persistent pain in the chest) or is known to have the virus. By signing below, you certify that none of the above are true. We are taking precautions to minimize exposure in accordance with state and county guidelines. 

Stroke: Stroke means that a portion of the brain does not receive oxygen from the bloodstream. The results can be temporary or permanent dysfunction of the brain, with a very rare complication of death. The chiropractic adjustment that is related to the vertebral artery stroke is called Extension-Rotation-Thrust Atlas Adjustment. We DO NOT use this type of adjustments on our patients. Other type of neck adjustments may also potentially be related to vertebral artery strokes, but no one is certain. The most recent studies (Journal of the CCA Vol. 37, No. 2, June 1993) estimate that the incidence of this type of stroke is 1 per every 3,000,000 upper neck adjustments. This means that an average chiropractor would have to be in practice for hundreds of years before they would statistically be associated with a single patient stroke.

Disk Herniations: Disk herniations that create pressure on a spinal nerve or the spinal cord are frequently successfully treated by chiropractors and chiropractic adjustment, traction, etc. This includes both in the neck and back. Yet, occasionally, chiropractic treatment (adjustments, traction, etc.) will aggravate the problem and rarely, surgery may cause a disk problem if the disc is in a weakened condition. These problems occur so rarely that there are no available statistics to quantify their probability.

Soft Tissue Injury: Soft tissue primarily refers to muscles and ligaments. Muscles move bones and ligaments limit joint movement. Rarely, a chiropractic adjustment (or treatment) may tear some muscle or 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 or mid-back. They extend from your back to your front chest area. Rarely, a chiropractic adjustment will crack a rib bone, and this is referred to as a fracture. This occurs only on patients who have weakened bones from conditions such as osteoporosis.  Osteoporosis can be detected on your x-rays. We adjust all patients very carefully, and especially with those who have osteoporosis on their x-rays. These problems occur so rarely that there are no available statistics to quantify their probability.

Physical Therapy Burns: Some machines we use generate heat. We also use both heat and ice, and occasionally recommend them for home use. Everyone’s skin has different sensitivity to these modalities and rarely, heat or ice can burn or irritate the skin. The result is a temporary increase in skin pain, and there may be some blistering of the skin. These problems occur so rarely that there are no available statistics to quantify their probability.

Soreness: It is common for chiropractic adjustments, traction, massage therapy, 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 change. It is not dangerous, but if it occurs, be sure to inform your clinician.

Other Problems: There may be other problems or complications that might arise from 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.

Chiropractic is a system of health care delivery, and therefore, as with any health care delivery system, we cannot promise a cure for any symptom, disease, or condition as a result of treatment in this clinic. We will always provide you with the best care and if the results are not acceptable, we will refer you to another health care provider who we feel may assist your condition.

If you have any questions on the above information, please ask your clinician. Once you have a full understanding, please initial and date below.


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ASSIGNMENT OF BENEFITS, ASSIGNMENT OF RIGHTS TO PURSUE ERISA AND OTHER LEGAL AND ADMINISTRATIVE CLAIMS ASSOCIATED WITH MY HEALTH INSURANCE AND /OR HEALTH BENEFIT PLAN (INCLUDING BREACH OF FIDUCIARY DUTY) AND DESIGNATION OF AUTHORIZED REPRESENTATIVE  

I hereby assign and convey directly to the above-named health care provider, as my designated authorized representative, all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for services, treatments, therapies, and/or medications rendered or provided by the above-named health care provider, regardless of its managed care network participation status. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize the above-named health care provider to release all medical information necessary to process my claims. Further, I hereby authorize my plan administrator fiduciary, insurer, and/or attorney to release to the above-named health care provider all Plan documents, summary benefit description, insurance policy, and/or settlement information upon written request from the above-named health care provider or its attorneys in order to claim such medical benefits.  

In addition to the assignment of the medical benefits and/or insurance reimbursement above, I also assign and/or convey to the above named health care provider any legal or administrative claim or chose an action arising under any group health plan, employee benefits plan, health insurance or tortfeasor insurance concerning medical expenses incurred as a result of the medical services, treatments, therapies, and/or medications I receive from the above-named health care provider (including any right to pursue those legal or administrative claims or chose an action). This constitutes an express and knowing assignment of ERISA breach or fiduciary duty claims and other legal and/or administrative claims.  

I intend by this assignment and designation of authorized representative to convey to the above-named provider all of my rights to claim (or place a lien on) the medical benefits related to the services, treatments, therapies, and/or mediations provided by the above-named health care provider, including the rights to any settlement, insurance or applicable legal or administrative remedies (including damages arising from ERISA breach of fiduciary duty claims). The assignee and/or designated representative is given the right by me to (1) obtain information regarding the claim to the same extent as me; (2) submit evidence; (3) make statements about facts or law; (4) make any request including providing or receiving notice of appeal proceedings; (5) participate in any administrative and judicial actions and pursue claims or chose in action or right against any liable party, insurance company, employee benefit plan, health care benefit plan, or plan administrator. The above-named provider as my assignee and my designated authorized representative may bring suit against any such health care benefit plan, employee benefit plan, plan administrator or insurance company in my name with derivative standing at provider's expense.  

Unless revoked, this assignment is valid for all administrative and judicial reviews under PPACA (health care reform legislation), ERISA, Medicare and applicable federal and state laws. A photocopy of this assignment is to be considered valid, the same as if it was the original.  

I request that payment of Medicare, Medicaid, Medicare supplement or other insurance benefits be made on my behalf to Alpha Life Chiropractic. I authorize any holder of medical information to release to Alpha Life Chiropractic, my clinician, CMS, caregiver, its agents and to my primary and other medical insurer. I agree that I am responsible for all amounts not covered by Medicare and/ or my insurer for which I am responsible including but not limited to any unmet portion of Medicare’s annual deductible. 

I HAVE READ AND FULLY UNDERSTAND THIS AGREEMENT. Please initial and date.


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Notice of Privacy Practices Patient Summary 

We understand that medical information about you is personal. We are committed to protecting medical information about you and your loved ones. 

Alpha Life Chiropractic employees are committed to protecting your personal health information and privacy. We will use your information to provide you care and treatment, create a record of the care and services you receive, bill your insurance in a timely fashion and operate our facility in a diligent manner. We will safeguard your information and share it only with those who need or are entitled to know. We will obtain your permission for other use or disclosure. You may ask to see, change, restrict or obtain a copy of your information and file a formal complaint if we fail to assure your privacy or information confidentiality. 

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. 

We are required by law to: 

· Keep medical information about you private.

· Provide you this notice of our legal duties and privacy practices with respect to medical information about you.

· Follow the most stringent state and federal law.

How we may use and disclose medical information about you: 

· We may use and disclose medical information about you to treatment (example, sending medical information about you to a specialist as part of a referral); to obtain payment for treatment (such as sending billing information to your insurance company or Medicare); and to support our care operations (example, using patient information to improve quality care).

· We may use and disclose medical information about you without your prior authorization for several other reasons. Subject to certain requirements, we may give out medical information about you without prior authorization for public health purposes, abuse or neglect reporting, health oversight audits or inspections, funeral arrangements, organ donation, workers' compensation purposes and emergencies. We also disclose medical information when required by law, such as in response to valid judicial or administrative orders.

We may also contact you for appointment reminders, or to tell you about or recommend possible treatment options, alternatives, health-related benefits, or services that may be of interest to you. 

Other uses of medical information 

In any other situation not involving routine care, financial and insurance matters we will ask for your written authorization before using or disclosing medical information about you. If you choose to authorize use or disclosure, you can later revoke that authorization by notifying us in writing of your decision. 

Your rights regarding your medical information: 

· In most cases, you have the right to look at or get a copy of medical information that we use to make decisions about your care, after you submit a written request. If you request copies, we may charge a fee for the cost of copying, mailing or related supplies. If we deny you request to review or obtain a copy, you may submit a written request for a review of that decision.

· If you believe that information in your record is incorrect or if important information is missing, you have the right to request that we correct the records, by submitting a request in writing that provides your reason for requesting the amendment. We could deny your request to amend a record if we did not create the information; if it is not part of the medical information maintained by us; or if we determine that record is accurate. You may appeal, in writing, a decision by us not to amend the record.

· You have the right to a list of the instances where we have disclosed medical information about you, other than for treatment, payment, health care operations or where you specifically authorized a disclosure, when you submit a written request. The request must state the time period desired for the accounting, which must be less than a 6-year period and starting after April 14, 2003. You will the request in paper form. We will inform you of the cost before you incur any costs.

All written requests or appeals should be submitted to our Privacy Officer listed at the bottom of this notice. 

If you wish to file a complaint because you feel that your privacy rights may have been violated, or you disagree with a decision we made about access to your records, you may contact our Privacy Officer (listed below). 

Finally, you may send a written complaint to the U.S. Department of Health and Human Services Office of Civil Rights. 

Under no circumstances will you be penalized or retaliated against for filing a complaint. 

U.S. Department of Health & Human Services 

Office of Civil Rights, 200 Independence Ave. S.W., Washington, D.C.20201 


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