Patient Account Responsibiltity

Health Insurance

Insurance Disclaimer: “A quote of benefits and/or authorizations does not guarantee payment or verify eligibility.  Payments of benefits are subject to all terms, conditions, limitations, and exclusions of the member’s contract at time of service. “

Insurance Liability for Payment:  Your health insurance company will only pay for services that it determines to be “reasonable and necessary.”  If your health insurance company determines that a particular service is not reasonable and necessary, or that a particular service is not covered under the plan, your insurer will deny payment for that service.  We suggest to all patients that they discuss this with our staff or your insurance to confirm that services are covered.

Under this arrangement, you are responsible for paying your co-pay, any non-covered portions, and any deductible you have yet to cover.  In addition, if your insurance company does not pay for our services, you agree to pay for the services provided in our clinic according to the below "No Health Insurance" information.

Beneficiary Agreement:  I understand that my health insurance company may deny payment for the services identified above, for the reasons stated.  If my health insurance company denies payment, I agree to be personally and fully responsible for payment.  I also understand that if my health insurance company does make payment for services, I will be responsible for any co-payment, deductible, or coinsurance that applies.

No Health Insurance

We offer uninsured patients the ability to enter into a contract with us (Crawford Chiropractic) and by doing so we are able to extend a contracted rate for services to patients. Our staff is able to provide these contracted rates to you upon request. Insured patients with a high copay/deductible may also enter into the contract for a more cost effective solution to care but upon signing up will decline the right to use their insurance or have claims sent to insurance.

Auto Accident, Worker's Compensation, Personal Injury

We accept Auto Accident, Worker’s Compensation, and Personal Injury cases and you are required to complete a lien and must provide all insurance company or attorney information for statements to be sent to.  You are ultimately responsible for payment for services rendered.  Worker’s Compensation cases must be pre-approved through your employer before starting treatment.

► All accounts regardless of responsibility are considered past due if no payment has been received within 30 days from receipt of invoice and are subject to a 1.5% monthly finance charge.  Delinquent accounts will be sent to a collection agency after 90 days that reports to major credit bureaus after we have exhausted all attempts to collect the balance with all applicable fees added to the account balance.

Consent for Use and Disclosure of Health Information

Purpose of Consent: By signing, you are consenting to the use and disclosure of your protected health information to carry out treatment, payment activities and healthcare operations by Dr. Crawford and his staff at Crawford Chiropractic (King Chiropractic Clinic, PC).  You also give consent for any other medical records to be released to this office from any other facility upon request and/ or any other person(s) you have listed below (if applicable).

Notice of Privacy Policy: Our Notice of Privacy Policy provides a description of the uses and disclosures we make of your health information.  You have the right to read this notice before you decide to sign this consent.  You have the right to obtain a copy of our Notice or Privacy Policy at any time.

Right to Revoke:  You have the right to revoke this consent at any time by giving us a written notice submitted to the Contact Person listed below.  This revocation does not affect any action we took in reliance on this consent before we received your revocation and we may decline any further treatment if you revoke this consent.

Patient/Doctor Communication:  By signing this consent, you give the right for Dr. Crawford and his staff to contact you via text, email, phone call or mail regarding your treatment, account and other communication.

You may obtain a copy of our Notice or Privacy Practices Policy, including any revisions, and this consent at any time by contacting the Office Manager, Brittney Jackson, RN – (706) 891-1011 

General Consent for Care and Treatment

You have the right, as a patient, to be informed about your condition and the recommended medical, surgical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved.  This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s).

This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services.

You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test and/or service ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions.

I voluntarily request a physician, and/or mid-level provider (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice.

By signing below, I certify that I have filled out this form to completion and the information provided is accurate and true to the best of my knowledge. I certify that by checking the boxes above for Patient Responsibility, Consent for Use and Disclosure of Health Information, and General Consent for Care and Treatment, I have read and consent to their contents and the check mark is the same as my signature.