Initials Consent to Treat

I hereby consent to the evaluation and treatment of my condition by a licensed chiropractor and/or a licensed physical therapist employed by Hopkins Health and Wellness Lakes Area clinic. I acknowledge my consent to receive treatment is/was voluntary and obtained after an initial evaluation. I understand I am responsible for informing Hopkins Health & Wellness ~ Lakes Area Physical Therapists and Chiropractors of any medical conditions I have, treatments and medications.

Initials HIPAA Notice of Privacy Practice / Bill of Rights I acknowledge that I have received/was offered a copy of the HIPAA Notice of Privacy Practices for this healthcare facility.

Initials Consent for Use and Disclosure By initialing this form you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities and health care operations.

Initials No Show and Cancellation Policy Hopkins Health and Wellness Lakes Area asks’ that you notify the receptionist at least 2 hours in advance when you are unable to keep your scheduled appointment. Our clinic scheduled your appointment and reserved time for you in good faith. Please assist us in our goal of providing the best possible care to all our patients.

______Initials I acknowledge that a fee of $25 may be assessed for a no show appointment or cancellation less than 2 hours.

Initials Private / Semi Open treatment options I understand that I have the option to be adjusted at the “Semi open” treatment area or a Private room. I acknowledge that anything I say in the semi open area may be heard by others. At any time I can ask for a private treatment room.

Initials Lelwica Enterprises / Snap Fitness According to Stark Law, we are required to inform you that Jim and Michelle Lelwica (Lelwica Enterprises) own Snap Fitness ~ Pequot Lakes.

I hereby freely and knowingly give consent to use personal information for the purposes described in these forms. X / / Patient, Guardian, or Legal next of kin Date Name of Patient (if signed by other) Reason Patient Did Not Sign: Minor Other: Relationship

Chiropractic Doctors: Dr. Michelle Lelwica, DC 31108 Government Drive JP Wesp, PT Dr. Justin Gronholz, DC Pequot Lakes, MN 56472 Physical Therapist

FINANCIAL POLICY AND PATIENT RESPONSIBILITY

FULL PAYMENT OF COPAY, CO-INSURANCE AND/OR DEDUCTIBLE AMOUNTS IS DUE AT DATE OF SERVICE. PATIENTS WITH INSURANCE COVERAGE: By signing this agreement, you are instructing your insurance company to make any payment for any reimbursable treatment, evaluation, diagnostic testing or durable medical equipment directly to Hopkins Health and Wellness Lakes Area. Your insurance policy is a contract between you and your insurance company. This office holds no party to that contract and will not be held responsible in the event that your insurance denies your claim. ASSIGNMENT OF INSURANCE BENEFITS In exchange for services and supplies rendered, I assign Hopkins Health and Wellness Lakes Area any insurance proceeds, including but not limited to health insurance, accident insurance, no-fault benefits and liability claim awards up to the amount of any unpaid balance on my account, including interest. In giving this assignment, I acknowledge that I will be responsible for any remaining balance due (with interest, if applicable). RECORDS RELEASE AUTHORIZATION I hereby authorize Hopkins Health and Wellness Lakes Area to release any information contained in my file to any insurance company, attorney or adjuster in order to process any claim for reimbursement of charges incurred for services rendered to me by you or any staff member of Hopkins Health and Wellness Lakes Area. INSURANCE FINANCIAL POLICY I agree to pay any insurance deductible, coinsurance or co pay amount at the time of each visit. I agree to pay for any nutritional supplements or durable medical equipment at the time of purchase. If my insurance company reimburses Hopkins Health and Wellness Center for any items purchased and paid for by me, Hopkins Health and Wellness Lakes Area will reimburse me for the same amount.

I understand that any insurance policy is a contract between my insurance company and me. If my insurance denies payment for any reason and/or my benefits are exhausted for any reason, I understand that I am responsible for payment in full of my account.

I hereby freely and knowingly give consent to use personal information for the purposes described in these forms. RADIOLOGY REFERRAL It is our office policy to send our films out to a board certified radiologist. This is not covered by your insurance. Therefore, if x-rays are taken a $21 fee per read (section/area of the body) will be incurred. I understand this is a separate charge not billed to my insurance that I am personally responsible for. X / / Patient, Guardian, or Legal next of kin Date Name of Patient (if signed by other)

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MEMO: __________________________OTHERPHYSICAL THERAPYCHIROPRACTIC CAREDMR CARE METHOD

Comments:If someone referred you, who was it?How did you hear about Hopkins Health & Wellness

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