1522 State Street unit A, Santa Barbarba, CA

ASSIGNMENT OF HEALTH PLAN BENEFITS AND RIGHTS

AS WELL AS AN APPOINTMENT AND/OR DESIGNATION AS MY PERSONAL REPRESENTATIVE

AND AN ERISA/PPACA REPRESENTATIVE AND BENEFICIARY

I understand and agree that (regardless of whatever health insurance or medical benefits I have), I am ultimately responsible to pay Inner Strength Medical + Wellness as well as all employees, employers, representatives, and agents thereof, (hereinafter collectively referred to as “Healthcare Provider”) the balance due on my account for any professional services rendered and for any supplies, tests, or medications provided. I hereby authorize payment of, and assign my rights to, any health insurance or medical plan benefits directly to Healthcare Provider for any and all medical/healthcare services, supplies, tests, treatments, and/or medications that have been or will be rendered or provided; as well as designating and appointing Healthcare Provider as my beneficiary under all health insurance or medical plans which I may have benefits under. I hereby authorize the release of any health status, conditions, symptoms or treatment information contained in your records that is needed to file and process insurance or medical plan claims, to pursue appeals on any denied or partially paid claims, for legal pursuit as to any unpaid or partially paid claims, or to pursue any other remedies necessary in connection with same. I hereby assign directly to Healthcare Provider all rights to payment, benefits, and all other legal rights under, or pursuant to, any health plan (including, but not limited to, any ERISA governed plan/insurance contract, PPACA governed plan/insurance contract) rights that I (or my child, spouse, or dependent) may have under my/our applicable health plan(s) or health insurance policy(ies).  I also hereby appoint and designate that Healthcare Provider can act on my/our behalf, as my/our Personal Representative, ERISA Representative, and PPACA Representative as to any claim determination, to request any relevant claim or plan information from the applicable health plan or insurer, to file and pursue appeals and/or legal action (including in my name and on my behalf) to obtain and/or protect benefits and/or payments that are due (or have been previously paid) to either Healthcare Provider, myself, and/or my family members as a result of services rendered by Healthcare Provider, and to pursue any and all remedies to which I/we may be entitled, including the use of legal action against the health plan, the insurer, or any administrator.  I hereby also declare that Healthcare Provider is my/our beneficiary regarding my/our health plan as contemplated by both ERISA and PPACA, and that Healthcare Provider can pursue any and all rights that I/we may have under state and/or federal law regarding my/our health plan. This assignment, appointment, and designation will remain in effect unless revoked by me in writing. It is my intent that the effective date of this document shall relate back to include all services, supplies, test, treatments, or medications that have been previously provided by Healthcare Provider. A photocopy or scan or this document is to be considered as valid and as enforceable as the original.

History of Present Illness:

Past Medical History

(Have you ever had the following: (circle “yes” or “no”/ leave blank if you are uncertain.)

Patient Social History:

Excessive Exposure

Indicate which of the below you have experienced in the last 1-2 months

1=Never; 2=Rarely; 3=Occasionally; 4=Frequently; 5=Constantly

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor’s office of any changes in my medical status. I also authorize the healthcare staff to perform the necessary services I may need

Patient Rights and Responsibilities

Patients/Clients have the right to be treated with dignity and respect.
• Patients/Clients have the right to fair treatment, regardless of race, ethnicity, creed, religious belief, sexual
orientation, gender, age, health status, or source of payment for care.
• Patients/Clients have the right to have their treatment and other patient information kept private. Only by law may
records be released without patient permission.
• Patients/Clients have the right to access care easily and in a timely fashion.
• Patients/Clients have the right to a candid discussion about all their treatment choices, regardless of cost or
coverage by their benefit plan.
• Patients/Clients have the right to share in developing their plan of care.
• Patients/Clients have the right to the delivery of services in a culturally competent manner.
• Patients/Clients have the right to information about the organization, its providers, services, and role in the
treatment process.
• Patients/Clients have the right to information about provider work history and training.
• Patients/Clients have the right to information about clinical guidelines used in providing and managing their care.
• Patients/Clients have a right to know about advocacy and community groups and prevention services.
• Patients/Clients have a right to freely file a complaint, grievance, or appeal, and to learn how to do so.
• Patients/Clients have the right to know about laws that relate to their rights and responsibilities.
• Patients/Clients have the right to know of their rights and responsibilities in the treatment process, and to make
recommendations regarding the organization’s rights and responsibilities policy.

• Patients/Clients have the responsibility to treat those giving them care with dignity and respect.
• Patients/Clients have the responsibility to give providers the information they need, in order to provide the best
possible care.
• Patients/Clients have the responsibility to ask their providers questions about their care.
• Patients/Clients have the responsibility to help develop and follow the agreed-upon treatment plans for their care,
including the agreed-upon medication plan. • Patients/Clients have the responsibility to let their provider know when
the treatment plan no longer works for them.
• Patients/Clients have the responsibility to tell their provider about medication changes, including medications given
to them by others.
• Patients/Clients have the responsibility to keep their appointments. Patients should call their providers as soon as
possible if they need to cancel visits.
• Patients/Clients have the responsibility to let their provider know about their insurance coverage, and any changes
to it.
• Patients/Clients have the responsibility to let their provider know about problems with paying fees.
• Patients/Clients have the responsibility not to take actions that could harm others.
• Patients/Clients have the responsibility to report fraud and abuse.
• Patients/Clients have the responsibility to openly report concerns about quality of care.
• Patients/Clients have the responsibility to let their provider know about any changes to their contact information
(name, address, phone, etc).
• Patients/Clients have the right and the responsibility to understand and help develop plans and goals to improve
their health.

CONSENT TO TREAT

I hereby request and consent to the performance of chiropractic manipulation and manual therapy
techniques and other chiropractic procedures, including various modes of physical therapeutic modalities
and procedures and diagnostic X-rays, where warranted, on me (or on the patient named below, for whom I
am legally responsible) by the doctor of chiropractic named below and/or other licensed doctors of
chiropractic who now or in the future work at the clinic or office listed below.
I have had an opportunity to discuss with the doctor of chiropractic named below the nature and purpose of
chiropractic adjustments and other procedures. I understand that results are not guaranteed.
I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are
some risks to treatment and diagnostic services including but not limited to:
Manipulation: increased pain or discomfort, fractures, disc injuries, strokes, dislocations and sprains.
Therapeutic Modalities and procedures: additional pain and discomfort. Endurance exercise may cause
increased risk of acute Myocardial Infarction (heart attack) in patients with known or possible cardiac
conditions.
Radiographs: ionizing radiation can be harmful to a fetus for those who are pregnant or might be pregnant.
I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely
upon the doctor to exercise judgment during the course of the procedure which the doctor feels at the time,
based upon the facts then known to him or her, is in my best interest. The doctor named below has
additionally explained the risks associated with my refusal of treatment.
I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions
about its content, and by signing below I agree to the above-named procedures. I intend this consent form to
cover the entire course of treatment for my present condition and for any future condition(s) for which I seek
treatment.