Reddingchiro, LLC

Dr. Caitlin Redding - NPI 125587633

5561 Pennell Rd Media, PA 19063

900 N. 4th St Philadelphia, PA 19123

FINANCIAL RESPONSIBILITY 

I understand that insurance billing is not a courtesy and is not a service provided and that I am at all times financially responsible to Reddingchiro, LLC for any and all charges. It is my responsibility to submit claims for an out of network provider office visit to my insurance company if I choose to do so. I understand that Dr. Caitlin Redding will not seek an assignment of benefits from my insurance company and that she is not a participating network provider for my insurance company. I understand that by signing this form that I am accepting financial responsibility as explained above for all payment for medical services and/or supplies received. 

APPOINTMENT POLICY 

It is the policy of most doctor’s offices to double and triple book their appointments because of potential cancellations and no-shows. This policy often creates substantial waiting for the patients. We feel that your time and schedule are important, and feel that this scheduling policy is unfair. This is why WE DO NOT OVERBOOK and why we ask for your cooperation in keeping your appointments or giving us as much notice as possible when canceling. Giving less than 24 hours must be given to avoid a cancellation fee equivalent in price for the missed appointment.

CONSENT TO TREAT

I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of therapy on the patient (or on the patient named below for whom I am legally responsible) by Dr. Caitlin Redding (Redingchiro, LLC), or other licensed doctors of chiropractic who now or in the future work at ReddingChiro, LLC. I have had an opportunity to discuss with the doctor or clinic personnel the nature and purpose of chiropractic treatments 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. 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. 

I have read the above consent. 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.  

NOTICE OF PRIVACY PRACTICES

I am required by the Health Insurance Portability & Accountability Act of 1996 (HIPAA) to provide confidentiality for all medical/mental health records and other individually identifiable health information in my possession. This Notice is to inform you of the uses and disclosures of confidential information that may be made by REDDINGCHIRO, LLC, and of your individual rights and REDDINGCHIRO, LLC's legal duties with respect to confidential information.

Ways in which I may use and disclose your protected Health information:

I may use and disclose at my discretion your medical records for each of the following purposes only: treatment, payment and health care operations.

● Treatment means providing, coordinating or managing mental health care and related services.

● Payment means activities such as obtaining payment for the health care services I provide for you from your insurance or another third party payer.

● Health care operations include the business aspects of running a practice.

I may contact you to provide appointment reminders or other services that may be of interest to you. I will disclose your protected health information to any person you identify that is involved in payment for your care. I will use and disclose your protected health information when required by federal, state or local law. There are certain situations in which as a health care provider I am required by ethical standards to reveal information obtained during treatment to persons or agencies even if you do not give permission. These situations are as follows: (a) If you threaten grave bodily harm or death to yourself or another person, I am required by ethical standards to inform the intended victim and/or appropriate law enforcement agencies; (b) if you report to me your knowledge of physical or sexual abuse of a minor child or of an elder (over 65) or any sexual conduct/contact with a minor, I am required by law to inform the appropriate child welfare or social agency which may then investigate the matter; (c) if I am required by a court of law (court order) to turn over records to the court or if I am ordered to testify regarding those records. 

Any other uses and disclosures will be made only with your written authorization. You will be provided with an authorization form upon request. A separate form will be needed for each request for release of information. The authorization for release of records is valid until it expires or is revoked. You may revoke authorization in writing. I am required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

Complaints

If you are concerned that your privacy rights have been violated, you may contact the person listed below. You may also send a written complaint to the United States Department of Health and Human Services. We will not retaliate against you for filing a complaint with the government or us. The contact information for the United States Department of Health and Human Services is: 

U.S. Department of Health and HUman Services HIPAA Complaint 7500 Security Blvd. Baltimore, MD 21244

Our Promise to You 

We are required by law and regulation to protect the privacy of your medical information, to provide you with this notice of our privacy practices with respect to protected health information, and to abide by the terms of the notice of privacy practices in effect.

Questions and Contact Person for Requests: This notice is effective June 1, 2018. If you have any questions or want to make a request pursuant to the rights described above, 

please contact: 

Reddingchiro, LLC

Attn: Dr. Caitlin Redding

5561 Pennell Rd

Media, PA 19063 

Phone: 484-441-3064

We may change our policies and this notice at any time and have those revised policies apply to all the protected health information we maintain. If or when we change our notice, we will post the new notice in the office where it can be seen. 

Caitlin Redding, DC 

Reddingchiro, LLC 

By clicking this box I acknowledge I have received and read the above and understand my operation, use of your information for treatment, payment and health care operations as stated above, my appointment policy, your financial responsibility and that you give consent to treat.