Family Chiropractic Agreement

Family Chiropractic Agreement

This Family Chiropractic Agreement (the Agreement) is made effective as of by and between Provider Name: with principal place of business at (Provider), and Patient/Responsible Party Name: of (Patient).

RECITALS

WHEREAS, Provider is licensed to provide chiropractic care and related therapeutic services and maintains clinical policies and records for family patients; and

WHEREAS, Patient and family members listed below seek chiropractic evaluation, treatment, and on-going care for injuries, conditions, or maintenance health services under the terms of this Agreement; and

WHEREAS, the parties desire to set forth the scope of services, fees, consents, and the respective rights and obligations of Provider and Patient.

NOW, THEREFORE

In consideration of the mutual covenants contained herein, the parties agree as follows:

1. DEFINITIONS

For purposes of this Agreement, "Services" means chiropractic examinations, manual adjustments, rehabilitative therapies, diagnostic referrals, and allied health services rendered by Provider or Provider's authorized staff. "Family Members" means the individuals identified in Section 2 as receiving treatment under this Agreement.

2. FAMILY MEMBERS & SCOPE OF SERVICES

Patient elects to enroll the following family members for evaluation and treatment. List each family member and relationship to Patient:

Provider will perform Services described in a plan of care established after evaluation. Services may include, but are not limited to:

Chiropractic adjustments / manipulative therapy    Therapeutic rehabilitation    Modalities (e.g., electrical stimulation, ultrasound)    Diagnostic referral (imaging/laboratory)

3. INFORMED CONSENT; ASSUMPTION OF RISK

Patient acknowledges receipt of a description of proposed treatments and potential risks. Patient authorizes Provider and staff to perform such examinations and treatments as may be considered necessary or advisable in the professional judgment of Provider. Patient understands that outcomes cannot be guaranteed and that inherent risks of chiropractic care may include bruising, soreness, aggravation of pre-existing conditions, and, in rare cases, more serious complications.

4. MEDICAL HISTORY; EXAMINATION

Patient represents that the medical history and disclosure of current symptoms are accurate to the best of Patient's knowledge. Provider will perform such physical and orthopedic examinations as are reasonably necessary to determine appropriateness of care. It is Patient's duty to inform Provider of any material changes in medical condition.

5. FEES, INSURANCE, AND PAYMENT

Patient agrees to pay Provider's fees for Services rendered. Provider may bill third‑party payors as a courtesy, but Patient is ultimately responsible for all charges not paid by insurance. Provider will inform Patient of applicable fees and estimated course of care where feasible.

By signing this Agreement, Patient authorizes Provider to bill insurance and to release medical information necessary for claims processing. Patient authorizes payment of benefits to Provider where assignment is permitted, but acknowledges Provider may require payment at time of service for co‑payments, deductibles, or non‑covered services.

6. CANCELLATION, MISSED APPOINTMENTS

Patient agrees to provide reasonable notice of cancellation. Provider may charge a missed appointment or late cancellation fee where permitted. Repeated missed appointments may result in termination of care.

7. CONFIDENTIALITY AND RECORDS

Provider shall maintain clinical records in accordance with applicable professional standards. Provider may disclose protected health information for treatment, payment, or healthcare operations as permitted by law. Patient may request access to records in writing and understands reasonable fees may apply for copying.

8. MINORS AND PARENT/GUARDIAN AUTHORIZATION

Where any enrolled Family Member is a minor, the undersigned Parent/Guardian represents that they have authority to consent to care and to execute this Agreement on the minor's behalf. Parent/Guardian will remain financially responsible for services rendered to minors until Provider receives written notice of guardianship change.

9. TERMINATION

Either party may terminate this Agreement upon written notice to the other. Termination does not relieve Patient of liability for fees incurred for Services rendered prior to termination. Provider reserves the right to withdraw care for safety concerns or non‑payment.

10. INDEMNIFICATION

Patient shall indemnify and hold harmless Provider and Provider's employees, officers, agents, and contractors from and against any claims, liabilities, damages, losses and expenses (including reasonable attorney's fees) arising out of Patient's breach of this Agreement, negligent acts, omissions, or willful misconduct, except to the extent caused by Provider's gross negligence or willful misconduct.

11. LIMITATION OF LIABILITY

Except for remedies available under applicable mandatory law, Provider's liability for damages arising out of or related to this Agreement shall be limited to direct damages capped at the total amount paid by Patient to Provider for the Services giving rise to the claim during the twelve (12) month period preceding the event. Neither party shall be liable for consequential, incidental, or punitive damages.

12. NOTICES

All notices required or permitted under this Agreement shall be in writing and delivered to the addresses set forth below or to such other address as a party may designate by written notice.

13. AMENDMENTS; WAIVER

No amendment to this Agreement shall be effective unless in writing and signed by both parties. Failure or delay by either party to enforce any right or remedy under this Agreement shall not constitute a waiver of that right or remedy.

14. GOVERNING LAW

This Agreement shall be governed by and construed in accordance with the laws of the state in which Provider maintains its principal place of business, without regard to conflict of laws principles.

15. ENTIRE AGREEMENT

This Agreement, together with any signed treatment consents or addenda referenced herein, constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior and contemporaneous agreements, whether written or oral.

16. SEVERABILITY

If any provision of this Agreement is determined to be invalid, illegal or unenforceable, the remaining provisions shall continue in full force and effect to the fullest extent permitted by law.

17. COUNTERPARTS; ELECTRONIC SIGNATURES

This Agreement may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument. Signatures transmitted by electronic means shall be binding and have the same force and effect as original signatures.

18. MISCELLANEOUS

Neither party may assign this Agreement without the prior written consent of the other, except that Provider may assign its rights to a successor practice. The headings in this Agreement are for convenience only and shall not affect interpretation.

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