Justin Weber

  
 newhope 
 chiropracltic 
 Acknowledgement of receipt of notice of privacy practices, consent for purposes of treatment, 
 payment and healthcare operations 
 I 
 acknowledge that I was provided a copy of the notice of privacy practices and that I have read them, or 
 declined the opportunity to read them, and understand that notice of privacy practices. I understand that this 
 form will be placed in my patient chart and maintained for six years 
 Patent records: Patient records, including X-rays, are the property of New Hope Chiropractic. These records are 
 only released with your written permission or as required legally. Some forms may have a fee. We request a 
 minimum of 24 hours notice for forms and letter to be completed by the provider. 
 Financial matters: Payment is due at the time services are provided unless prior arrangements have been made. 
 All charges will be explained to you prior to any service being performed. 
 Medicare: The office will accept assignment for Medicare. Patients are responsible for their copayment and 
 payment for any services not covered by Medicare. 
 Personal Injury: In most cases, this office will accept assignment for payment. If the office accepts assignment 
 for payment the patient is still legally responsible for their account balance. Patients will be required to sign a 
 lien in the case of personal injuries
 Workers' Compensation: Work-related injury cases are accepted on assignments with permission of the 
 employer and prior authorization from the employer's compensation insurance carrier. 
 Massage Cancellations: In an effort to accommodate all patients, we ask that all patients keep their scheduled 
 appointments or proceed us with 24 hours notice (1 business day). Our office has a $25 administrative fee for 
 those who miss their massage appointments without advance notice. This policy helps to ensure that we can 
 accommodate you when in medical need. 
 I have read the above statements and accept these conditions. 
 Print name: Alan Pearson
 Signature: 
 Gerorth 
 Date: 
 13/23/03
 Dr Ryan Brooks Chiropractic Physician 
 Address. 4746 S. Florida Ave. Lakeland, FI 33846 Phone. 863.462.1460 
