Healthcare Chiropractic Contract

HEALTHCARE CHIROPRACTIC CONTRACT

Provider Name:    Provider Address:

Patient Name:    Agreement Date:

1. Patient Information

Male    Female    Other    Prefer not to say

2. Emergency Contact

3. Insurance Information

4. Medical History

5. Proposed Treatment and Consent

The Provider will perform chiropractic evaluation and treatment, which may include spinal manipulation, mobilization, soft tissue therapy, rehabilitative exercise, modalities such as electrical stimulation or therapeutic ultrasound, and other mutually agreed procedures. These treatments are intended to reduce pain, restore function, and improve physical health.

Patient acknowledges that, while generally beneficial, chiropractic treatment involves potential risks including but not limited to increased pain, paralysis, fracture, disc injuries, stroke, and other complications. Patient has had opportunity to ask questions and has been informed of alternative treatments. Patient consents to the treatment plan proposed by Provider.

I hereby authorize Provider: to administer chiropractic care as needed and agreed upon during the course of treatment.

I understand I may revoke this consent at any time in writing, and that revocation will not affect any actions taken prior to receipt of written notice.

6. Fees, Billing and Assignment of Benefits

Patient agrees to pay all charges for services rendered. Provider will bill insurance as a courtesy when assignment of benefits is executed. Patient is responsible for co-payments, deductibles, non-covered services, and any portion not paid by insurance.

Assignment of Benefits: I assign to Provider all rights and claims for payment of medical benefits to which I am entitled for services provided. I authorize Provider to submit claims and receive payment directly from my insurer to the extent permitted by law.

Yes, I assign benefits to Provider    No, I will pay and seek reimbursement myself

7. Cancellation and No‑Show Policy

Patient agrees to provide at least 24 hours' notice for cancellations. Provider may impose a cancellation or no-show fee for missed appointments. Repeated missed appointments may result in termination of care.

I acknowledge and accept the cancellation/no-show policy

8. Confidentiality and HIPAA Acknowledgment

Provider will maintain the confidentiality of patient health information in accordance with applicable privacy laws. Patient acknowledges receipt of Provider's Notice of Privacy Practices and consents to the use and disclosure of protected health information for treatment, payment, and healthcare operations as described in that notice.

I acknowledge receipt of the Notice of Privacy Practices and consent to release information for treatment and billing

9. Authorization to Release Records and Expiration

I authorize Provider to release medical records and billing information to my insurer, referring physician, or other third parties as necessary for treatment and payment. This authorization is valid until the expiration date below or until revoked in writing.

10. Limitations of Liability and Indemnity

Provider will exercise reasonable care and skill in providing chiropractic services. Provider does not warrant that treatment will be effective for every condition. Patient agrees to indemnify and hold Provider harmless from claims arising from patient's negligence or failure to follow instructions. Provider's liability for any claim shall not exceed amounts actually paid by patient for the specific services giving rise to the claim.

11. Dispute Resolution and Governing Law

In the event of dispute arising under this Contract, the parties agree to submit to good faith negotiation and, if unresolved, to non-binding mediation prior to initiating litigation. This Contract shall be governed by the laws of the State of .

12. Consent for Electronic Communication

Patient consents to receive appointment reminders, treatment information, and billing communications via phone, SMS, and email unless patient opts out in writing. Patient understands standard electronic communications are not guaranteed to be secure.

I consent to electronic communications

13. Minor Patient / Guardian

If the patient is a minor or legally incapacitated, the undersigned certifies that they are the parent or legal guardian authorized to consent to treatment and execute this Contract on behalf of the patient. Provide relationship to patient below.

14. Certification

By signing below, I certify that the information provided in this Contract is true and complete to the best of my knowledge, that I have read and understand the terms set forth above, and that I consent to the chiropractic treatment and billing practices described herein.

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