Section 3: Informed Consent & Legal Authorizations
3.1 Integrated Informed Consent Agreement
A. Evaluation & Therapeutic Care: Chiropractic, functional neurology, physical medicine, nutrition, and massage offer major benefits but carry minimal risks (e.g., muscle/nerve irritation). Rare complications secondary to cervical adjustments include vertebral artery injury/stroke (1 in 1-2 million adjustments). Examinations are performed prior to care to assess suitability.
B. Passive Therapies & Modalities: The following non-diagnostic modalities support recovery and pain management:
Contraindications: DVT, pacemakers, pregnancy, epilepsy, MS, open wounds.
C. Class IV Laser Therapy & Acupuncture: Eye protection is strictly required during Class IV laser administration. Acupuncture procedures utilize single-use, sterile disposable needles to eliminate cross-contamination risks.
CONSENT ACKNOWLEDGMENT: I knowingly and willingly consent to evaluation, care, and the specific therapies listed above across my current and subsequent visits. I confirm that all my questions have been answered to my satisfaction and disclosures of risks have been reviewed.
3.2 Appointment Reminders & Cancellation Policy
Please provide 24 hours' notice for cancellations/rescheduling. A $75 fee may be assessed for missed appointments, "no-shows", or late cancellations without 24-hour notice. Arriving 20+ minutes late may be treated as a missed appointment. Cancellation fees are directly billed to your account and are not billable to insurance.
3.3 Authorizations, Medical Records & Financial Responsibility
1. Information & Assignment: I authorize release of medical records necessary for processing claims or care continuity. I assign all direct insurance/third-party payment benefits to Live Well Health, PC.
2. Personal Responsibility: I understand that all services rendered are charged directly to me and I am personally responsible for payment regardless of insurance coverage or legal claim outcomes.
3. Records Release: Valid for 6 months. Authorizes bilateral exchange of medical records, exam reports, chart notes, and imaging (X-Ray/CT/MRI) with treating facilities and legal counsel.
3.4 Irrevocable Doctor's Lien & Right to Recovery
In consideration for receiving care prior to payment, I hereby grant Live Well Health, PC / Concussion & Whiplash Clinic a legal lien against any and all proceeds of legal causes of action, settlements, or verdicts arising from my accident. I explicitly direct my attorney to withhold and pay owed clinic balances directly from settlement proceeds. This agreement is irrevocable without written clinic consent.
3.5 HIPAA Privacy Acknowledgment
I acknowledge that I have been offered and reviewed a copy of this office's HIPAA Notice of Privacy Practices.