TERMS OF ACCEPTANCE

When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective.

Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment.

Adjustment: An adjustment is the specific application of forces to facilitate the body's correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine.
Health: A state of optimal physical, mental and social well being, not merely the absence of disease or infirmity.
Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alternation of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body's innate ability to express its maximum health potential.

We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However. if during the course of a chiropractic spinal examination, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we may recommend that you seek the services of another health care provider.

OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body's innate wisdom. Our procedures are specific in correcting vertebral subluxations.

All my questions regarding the doctor's objectives pertaining to my care in this office have been answered to my complete satisfaction.

I, therefore accept chiropractic care on this basis.

Consent to evaluate and adjust a minor child.

PERSONEL INJURY FORM

ATTORNEY INFORMATION

WITNESS

We would like to take a moment to welcome you to our office and to assure you that you will receive the very best care available for your injury. In order to familiarize you with the financial policy of our office, I would like to explain how your medical bills will be handled.

PARTY RESPONSIBLE:
If you were involved in an auto accident in your own vehicle, we will bill the medical payments portion or Personal Injury Protection portion of your insurance policy to cover the treatment charges incurred in our office.

MED PAY: If you were a passenger in another vehicle, the insurance company which insures the automobile may be billed for your medical services incurred. PIP: If you were a passenger in another vehicle, and you own a car which has PIP coverage, the insurance company which
carries your policy will be responsible to pay your medical bills. PARTY: If another vehicle has caused the accident, we will only bill your automobile MedPay or PIP policy for coverage, this office does not bill 310 PARTY claims.

It is also to your advantage for our office to bill your own health insurance policy for your medical services, providing your policy does not state otherwise.

ATTORNEY LIENS:
If you hire an attorney to represent you, it is our office policy to have your attorney sign a Doctor's Lien. This will guarantee direct payment to our office for any unpaid balance upon settlement of your case. We retain the right to first submit all charges to your private and/or auto insurance policy for payment. Further, this office does not discount or reduce the amount of your balance based upon the outcome of your settlement,

RESPONSIBLE FOR PAYMENT:
As a courtesy to you, we will gladly submit your charges to your insurance company(ies) and/or your attomey; however, all services rendered by this office are charged directly to you, and ultimately, you are personally responsible for payment of these charges, regardless of any insurance reimbursement or settlement you may or may not receive.

Once again, we welcome you to our office. We hope that this has answered any questions that you might have about our financial arrangements. If, at any time, you have further questions about your care, please, don't hesitate to ask.

I authorize payment of medical benefits to the chiropractor listed below for all professional services rendered to me by his/her office.

I authorize the release of any health information necessary to process this claim. A photocopy of this authorization shall be as effective and valid as the original.

Any sum of money paid under this assignment shall be credited to my account and I shall be personally liable for any unpaid balance to the Doctor. I understand that the Chiropractor will not bill me for any charges over and above the insurance payment, other than the applicable co-payments, coinsurance or deductibles.

Pay to Doctor:

Kevin Stewart, D.C.
Stewart Chiropractic
1420 W. Kettleman Ln. Ste. K-1
Lodi, CA 95240