fill out the forms prior to your visit

Learn more about the patient journey when you visit us! Doyle Chiropractic in Simpsonville, SC, can be reached at 864-881-4221.

HIPAA Authorization

Before we begin any health care operations, we require you to read and sign this form stating that you understand the below item. If you refuse to sign this form, the doctor reserves the right to refuse care.

Authorization:

By signing below, you authorize this office/provider to complete a consultation and examination on the above.

Authorization for X-Ray with Release:

By signing below, you declare, to the best of your knowledge, that there is no chance you are pregnant at this time. By signing below, you declare that you have no known limitations that would be contraindicated for an x-ray evaluation. By signing below, you consent to the taking of x-rays if there is a determined need.

Acknowledgment of Assignment of Benefits:

By signing below, you acknowledge that you are fully responsible for all services rendered. By signing below, you further acknowledge understanding that your health and accident insurance information policies are an arrangement between you and your carrier, and that you may be required to pay some or all of the fees charged to your account. By signing below, you hereby assign benefits to be paid directly to this office/provider by your third-party payer, e.g., insurance company, attorneys, etc. By signing below, you agree that this is a non-rescindable agreement and failure to fulfill this obligation will be considered a breach of contract between you and this office.

CMS-1500 Health Insurance Claim Form:

By signing below, you acknowledge and agree that the CMS-1500 Health Insurance Claim Form Box 12 and Box 13 will state "Signature on File". Box 12 Reads as follows: "PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below." Box 13 Reads as follows: "INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below."

Acknowledgement of Notice of Privacy Practices:

We are very concerned with protecting your personal health information. There may be times our office may need to contact you regarding office matters. By signing below, you have authorized this office to contact you for office-related matters in the following manner: phone-work-home or mobile, e-mail, and regular mail. Messages may be left on an answering device/voicemail, or with the person answering your phone-home-work-mobile. Also, in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), updated September 23, 2013, this office is obliged to supply you with a copy of the office privacy policies and procedures upon request. This document outlines the use and limitations of the disclosure of your personal health information and your rights as a patient. By signing below, you have acknowledged that you have been offered a copy of this document.

Acknowledgement of Treatment Plan:

By signing below, I acknowledge that, if accepted for care, I may be presented with a chiropractic treatment plan resulting in one or more of the following services: chiropractic adjustments, examinations, and supportive therapies and procedures.

Acknowledgement:

By signing below, you acknowledge that you understand and agree with the policies and procedures outlined in this TERMS of ACCEPTANCE form. By signing below, you acknowledge and certify that all the information given to the office/provider in the INTAKE forms is true and accurate to the best of your knowledge.