The Purpose of This Compliance Program

The Purpose of this Compliance Program

Our practice will view the implementation of the compliance program as comparable to a form of preventative medicine to protect against fraudulent or erroneous conduct. This will assist our practice by developing and implementing internal controls and procedures that promote adherence to Federal Health Care programs and private insurance program guidelines and requirements. By implementing this compliance program, our practice can help prevent and reduce fraudulent or erroneous conduct, as well as furthering our mission to provide quality care to our patients.

(Enter Name of Practice)

I. Standards for Code of Conduct / Written Policies and Procedures 3-4

II. Compliance Monitoring Efforts of Staff Policies 4-5

III. Training on Practice Ethics 6-9

IV. Internal Monitoring / Auditing for Billing 9-10

V. Lines of Communication for Compliance Activities 10

VI. Designation of Compliance Officer and Their Activities 10-11

VII. Proper Response to Detected Violations 11

VIII. Appendix A - Additional Risk Areas 12-15

IX. Appendix B – Additional Policies 16-17

Employee Acknowledgment Form 18

Informed Consent Form 19

Hardship Agreement Form 20

I. Standards for Code of Conduct / Written Policies and Procedures:

A. The Company and all Company employees must comply with this Plan’s requirements. Additionally, the Company will give all major vendors who conduct business with the Company a copy of this Plan to help insure that all business will be conducted according to the Plan.

B. Our standard for code of conduct and written policies is stated as: “This practice bills only for services that are actually rendered, codes accurately, documents medical necessity and appropriateness, and address to all payer contracts.”

C. This “standard for code of conduct” will be reviewed annually and revised as necessary.

D. The Acknowledgment Form will be signed by every employee, who should in return receive a copy of this statement during training.

E. Overview of Standards of Conduct: All Company employees must conduct all business activities honestly and fairly. Because the number of laws, regulations, and professional rules that govern health care is so expansive; this Plan does not attempt to list them. However, there are several particularly important “universal” standards of conduct with which all employees must be familiar and follow.

A violation of any of the following standards is a serious violation of the law and will result in disciplinary action, including possible termination of employment as listed in the office policy handbook. · The Company and its employees may not make any false statement of any kind in any claim or application for health care benefits or payments. · The Company and its employees will not retain any overpayment of funds from any federal, state or private insurance program that have not been properly paid. · The Company and its employees will not submit any claim for health care benefits when that person providing the service is not properly licensed or has falsely claimed to be a specialist. · The Company and its employees will not submit any claim for health care benefits if the services were not medically necessary. · The Company and its employees will not pay or offer to pay any source for referrals of individuals to the Company for professional services. Neither the Company nor any employee may receive any

Page | 3 © Copyright 2012 by Dr. John D. Davila. Reproduction of any of this material is strictly prohibited. payment from any source for referrals of individuals to the Company for professional services. · The Company and its employees will not present a claim to any governmental agency or other payer that is for an item or service that the employee knows was not provided or that the employee knows is false. Neither the Company nor any employee will make any false representations regarding coverage of any patient services. · The Company and its employees will not engage in any conduct or scheme to cheat or defraud any healthcare benefit program or governmental agency for any reason. · The Company and its employees will not misappropriate any funds or other assets from any health care benefit program or governmental agency. · The Company and its employees will not falsify or conceal any facts concerning the delivery of services or payments of benefits in connection with any health care benefit program. · The Company and its employees will not prevent or delay the required communication of information or records related to a health care offense. · The Company and its employees will not use any funds obtained improperly from any health care program to operate any business activity anywhere.

“Appendix A” to this Plan describes other examples of other standards of conduct with which the Company and its employees must comply. Additionally, employees must comply with all other Company policies and procedures, including those in the policy and procedure manuals distributed to or available for employees’ review.

II. Compliance Monitoring Efforts of Staff Policies.

A. This document will serve as our written compliance manual procedure/policies for staff as it applies to corporate and insurance compliance.

Note: Employees will be given access to a reference copy of the staff policy handbook during training, this will be documented.

Our practice will conduct yearly checks to make sure all correct and potential practice employees are not listed on the OIG (www.oig.hhs.gov) or GSA lists of individuals excluded from participation in Federal Health Care or Government Procurement programs. All new employees will be checked before they are hired and current employees will be checked once per calendar

If the office has actual notice that a Screened Person has become an Ineligible Person, the office shall remove such Screened Person from responsibility for, or involvement with, the office’s business operations related to the Federal health care programs and shall remove such Screened Person from any position for which the Screened Person's compensation or the items or services furnished, ordered, or prescribed by the Screened Person are paid in whole or par, directly or indirectly, by Federal health care programs or otherwise with Federal funds at least until such time as the Screened Person is reinstated into participation in the Federal health care programs.

B. Enforcement and Discipline

In order to ensure consistent enforcement of Company’s compliance policies, the employee performance evaluation process will include consideration, as discussed above, of the employee’s compliance with this Plan and other relevant policies and procedures.

Any employee who is found to have engaged in dishonest conduct is subject to disciplinary action, including possible suspension or termination of employment. Any employee who engages in the following conduct will be subject to disciplinary action, including suspension or termination as spelled out in The Office Policy Manual:

· Authorizing or participating in any action that constitutes a violation of applicable laws, regulations or professional standards of the Company; · Failing to promptly report, or withholding information about, a known or possible violation of applicable laws, regulations or professional standards of the Company; · Attempting to retaliate, or participating in retaliation, against an employee who reports a compliance issue in good faith; · Reporting a compliance issue the employee knows is false or misleading; or · Interfering, or failing to cooperate fully, with the Company’s efforts to investigate or address any compliance report or issue. · Interfering, or failing to cooperate fully with the Company’s Compliance Plan.

C. Violations of the practice’s compliance policies will result in consistent and appropriate sanctions including the possibility of termination against the offending individual. The policy applies to staff members who fail to report violations of the compliance program and flexibility to account for mitigating circumstances. All discipline will be handled as per the office policy manual. Page | 5 © Copyright 2012 by Dr. John D. Davila. Reproduction of any of this material is strictly prohibited. III. Training on Practice Ethics (to prevent fraudulent claims):

A. Where the practice is vulnerable:  Coding & Billing  Reasonable & Necessary Services  Documentation  Improper kickbacks / Self-Referrals  Anti-Trust Issues  Collection Efforts

1. Our practice will not bill for items or services not rendered or provided, double bill, bill for non-covered services as if covered, misuse of NPI #, unbundling services, improper use of modifiers, or upcode. We will code and bill based on proper documentation with attention to diagnosis coding. a. 240.1.3 - Necessity for Treatment (Rev. 23, Issued: 10-08-04, Effective: 10-01-04, Implementation: 10-04-04) B3-2251.3 The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function. b. A - Maintenance Therapy Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy. The AT modifier must not be placed on the claim when maintenance therapy has been provided. Claims without the AT modifier will be considered as maintenance therapy and denied. Chiropractors who give or receive from beneficiaries an ABN shall follow the instructions in Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, section 20.9.1.1 and include a GA (or in rare instances a GZ) modifier on the claim.

2. Our practice is aware that Medicare will only pay for services that meet the Medicare definition of necessary and Medicare may deny payment for a service that a doctor believes is clinically appropriate but not reasonable and necessary. Therefore our practice will only bill for services reasonable and necessary for the doctor diagnosis code and the Tx of a patient. We will be able to provide documentation to support the service provided.

Page | 6 © Copyright 2012 by Dr. John D. Davila. Reproduction of any of this material is strictly prohibited. 3. Our office will document a medical record that precisely states what services were actually provided and will be used to validate:

Documentation a. Site of Services – Was the site the service was performed at accurately reported?

b. Appropriate service provider – Was the provider of the service accurately reported?

c. Accuracy of billing – Did the billing accurately reflect the services reported in the documentation?

Our documentation will be: i. Complete and legible ii. Reason for patient encounter iii. Relevant history iv. Physical exam findings v. Prior diagnostic test results and X-Ray findings vi. Diagnosis vii. Treatment plan viii. Date and legible identity of observer ix. Appropriate health risk factors identified, the patient’s progress, changes in Tx or revision of Dx

d. Annually updated clinical forms i. Encounter Forms ii. Registration iii. History iv. Physical v. Super bill

e. Patient Record Confidentiality i. Our staff will protect the confidentiality of all patients and provider records ii. Our staff will abide by all state and Federal rules regarding privacy

f. Locum Tenens (Fill-In Doctors) i. L.T. allowed for sixty (60) days under Medicare guidelines ii. A doctor in our same group/Tax ID # will have services billed under that doctor’s NPI #

g. The following practices will help to ensure the CMS-1500 form has been filled out properly to show: i. Link diagnosis codes to E/M services

Page | 7 © Copyright 2012 by Dr. John D. Davila. Reproduction of any of this material is strictly prohibited. ii. Link diagnosis codes to personal history iii. Link diagnosis codes with corresponding TX iv. Correct use of modifiers v. Provide Medicare with additional information about patient’s insurance coverage h. Our policies will ensure compliance with anti-kickback statutes and physician self referral law by: i. Remuneration for referral will not be tolerated because it can obstruct medical decision making and patient case ii. Prohibit giving (or receiving) anything of value to induce referrals iii. All arrangements with physician practice regarding referrals of business to outside groups, be of fair market value iv. All contracts regarding referrals will be reviewed by legal counsel to deter any self-referral or anti-kickback statute violation v. Due to anti-trust laws, our office is prohibited from, and will not enter into any agreement that will fix or reduce price competition vi. This practice will make a legitimate offer to collect all money owed as follows:  Forwarding statements to responsible party for up to 90 days.  Referral to collection agency for up to three (3) years.  Debt may be written off after a 90 day cycle. i. Compliance Training i. All employees will receive training on how to perform their jobs in compliance with the standards of practice ii. Each employee should understand that compliance is a condition of continued employment iii. Compliance Training will be explained to our employees that it is necessary to limit the practice vulnerability to fraud and abuse of any program or patient iv. New employees will be trained within thirty (30) days of their start date and it will be documented and employees will receive refresher training on an annual basis j. Coding and Billing Training (to include): i. Coding requirements ii. Claim development or submission process iii. Signing a form for a physician without the physician’s authorization iv. Ramification of altering medical records v. How to report misconduct vi. Proper billing standards and procedures and submission of accurate bills for services rendered to all beneficiaries

Page | 8 © Copyright 2012 by Dr. John D. Davila. Reproduction of any of this material is strictly prohibited. vii. Legal sanctions for submitting false or reckless billings viii. Inform physician that claims can not be filed for physician services when rendered by a non-physician

k. In-House Training i. Training will be conducted in-house and at seminars. ii. Training will be completed for all employees in the key risk areas of compliance. (If a third party billing company is used, our office will train our staff to ensure that documentation is at a level that is adequate for proper claims to be submitted.) iii. Our office will have updated ICD-9/HCPCS/ and CPT manuals along with Carrier bulletins available to all employees.

IV. Internal Monitoring / Auditing for Billing

A. Retention of records Our office will maintain the following in accordance with Federal and state regulations. 1. Compliance records are kept at the office site 2. Business records are kept at the office 3. Medical records are kept at the office site *Note: The compliance officer will keep an updated binder of compliance related activities including:  Compliance meetings  Educational activities  Internal audits  Documentation of violations & action taken  Reported errors in billing

B. Our office destroys files that have aged over ten (10) years without an entry based on state regulation on documentation.

C. Our practice will document its efforts to comply with applicable Federal Health programs. And keep a record of any request or response from Government Agency charged with administering a Federal Health Care Program.

D. Records will be secured against loss, destruction, unauthorized access, unauthorized reproduction, corruption or damage.

E. If our office is closed, we will inform every patient of the place of the records and who the custodian is so all records can be accessed. If the office is sold, we will transfer all record to the new owners of the clinic.

Page | 9 © Copyright 2012 by Dr. John D. Davila. Reproduction of any of this material is strictly prohibited. F. Auditing and Monitoring Claims Submission The FDCA collects information. The Insurance CA inputs all new patient data and charges then bills all charges to patients and insurance companies every morning. All claims are sent electronic format via a billing company.

G. Claims Audits 1. Claims will be audited retrospectively to claims submission. The first audit will be held during the initial ninety (90) days after implementation of the education and training program to create a benchmark against which to measure future compliance effectiveness. 2. Periodic audits can follow once a year once compliance has been achieved. Audit Formula - pull five (5) records / physician to confirm a. Service provided b. What diagnosis code is the physician using c. Check to see if diagnosis codes are too general for “reasonable and necessary” purposes, to include up coding, down coding, or unbundling d. Check for data entry errors e. Confirm all orders are written and signed by physician f. Confirm all tests ordered were actually performed and documented g. Only tests performed were billed h. Review code modifiers used that correspond to documentation i. Appropriate Action Taken

V. Lines of Communication for Compliance Activities

A. Open Door Policy Our office has an “open door policy” between physicians and staff/employees to make aware any questions about billing that may arise.

For Example: Reports to be posted or brought to the physician will include the following: 1. Employee must believe in good faith a claim or process to be fraudulent or erroneous 2. State erroneous conduct or violation of the compliance program 3. Employee understands the process is confidential 4. Employee understands there will be no retribution against them for their report

VI. Designation of Compliance Officer and Their Activities

To administer our compliance program, our practice will name (ENTER NAME OF COMPLIANCE OFFICER) as our compliance officer. He/She is to be sufficiently independent in their position so as to protect against any conflicts of interest that may arise from performing duties.

Page | 10 © Copyright 2012 by Dr. John D. Davila. Reproduction of any of this material is strictly prohibited. Their duties are as follows: A. Oversee compliance program B. Establish audit methods to reduce the practice’s vulnerability to fraud and abuse C. Periodical reviews / revise compliance program D. Develop and coordinate training of employees on compliance program E. Ensure all employees and staff are checked against Dept. of Health and Human Services Office of Inspector General’s list of parties debarred from Federal programs at least one time per year F. Ensure staff knows and complies with federal and state statutes, regulations and standards G. Investigate any report of possible unethical or improper business practice H. Monitor subsequent corrective actions or compliance

VII. Proper Response to Detected Violations

Auditing and Monitoring of Policy

A. The person in charge of compliance will be in charge of periodically reviewing policies and procedures for accuracy and completeness. Changes will reflect changes in CPT and government regulations.

B. Action that will be taken within sixty (60) days from date of detection of problem. 1. Repayment / offsets to other billings. If over payment is detected, it will be reimbursed to the insurance company within 60 days. If the company allows the amount to be debited of the next check, our office will agree. 2. Seek legal advice 3. Consult with coding/billing expert to determine next course of action

C. Proper documentation includes 1. Date of incident 2. Name of reporting party 3. Name of party who took action 4. Follow-up action taken

**NOTE: Key Signs when compliance program in not working  High rate of rejected claims  High rate of suspended claims  Placed on Pre-Payment review by carrier

A. Reasonable and Necessary Services 1. Dictated by National Coverage Determination (NCD). This is done in order to determine the reasonableness of our services. For more information, visit www.cms.gov.

2. Advanced Beneficiary Notices Physicians are required to provide an ABN prior to any treatment they provide if they feel the treatment may not be covered by Medicare as “medically necessary”.

The waiver (ABN) lets the patient acknowledge that coverage is uncertain or yet to be determined, and that the patient promises to pay the bill if Medicare does not.

**PATIENTS WHO ARE NOT NOTIFIED BEFORE THEY RECEIVE SUCH SERVICES ARE NOT RESPONSIBLE FOR PAYMENT**

The ABN should cover the following: a. Be in writing b. Identify the specific service that may be denied (CPT code is recommended) c. State specific reason why the physician believes that service may be denied d. Be signed by the patient acknowledging that the required information was provided and that the patient assumes responsibility e. The CMT is billed with a GA modifier on the date the waiver is signed on a non-medically necessary setting

An ABN (Waiver) will not be acceptable if: a. Patient is asked to sign a blank form b. The ABN is used routinely without regard to particularized need c. If the Medicare approved waiver is not the actual waiver signed by the patient

ABN and Diagnostic Testing/Excluded Services “In Chiropractic, X-rays, exams and therapies are not a covered service under national coverage rules.” This statement on an ABN would inform the patient that the doctor is to be paid for all excluded services by the patient.

The physician should indicate on the claim that the claim is being submitted for the purpose of receiving a denial, in order to bill a 2nd insurance carrier. This is done by indicating there is a secondary carrier on the claim and by using the GP-GY modifier.

POSSIBLE VIOLATION OF ABN (WAIVER) a. Bill patient a fee for filing claims b. Do not accept assignment for Dx testing c. Do not accept assignment for Medicare/Medicaid patient d. Collect more than Medicare allowable e. Bill patient for service deemed not medically necessary without waiver f. Failure to accept assignment as a participating provider g. Billing more than allowed for non-assigned claims h. Failure to make a refund within thirty (30) days of request

B. Physician Billing Practices

Third Party Billing Services A physician may contract with a billing service on a % basis. However, THE BILLING SERVICE CANNOT DIRECTLY RECEIVE MEDICARE PAYMENTS MADE TO THE PHYSICIAN (42 U.S.C. 1395u(b)(6) is the ruling).

Medicare payments can only be made to the beneficiary or physician who accepted assignment. PAYMENT MUST BE SENT DIRECTLY TO THE PATIENT OR THE DOCTOR.

Non-Participating Bill Practices 1. A non-participating physician may not bill more than the limiting charge for a service. **NOTE: Each violation up to $10,000 and/or exclusion from Federal programs (knowingly and willfully violate policy) up to 5 year.

2. Refund of limiting charge violation must be made within thirty (30) days. **NOTE: Same penalty as in B.1.

3. Refund of Not Medically Necessary Treatment (Non-Assigned Claims) 42 U.S.C. 1395u (L)(A)(iii) mandates that a non- participating physician must refund payments from a Medicare beneficiary if it is later determined that the services rendered were not reasonable and necessary. **NOTE: Same penalty as in B.1.

Page | 13 © Copyright 2012 by Dr. John D. Davila. Reproduction of any of this material is strictly prohibited. Professional Courtesy Definition: A physician who waives all or part of the fee for services provided to the physician’s staff, other doctors, or family. In recent times, it has also meant waiver of co-insurance obligations. Our office allows for professional courtesy to be extended to DCs, DC students, staff/former staff and immediate family members of staff/former staff and business partners.

No Out-Of-Pocket Expense 1. Our office allows for professional courtesy to be extended to DCs, DC students, staff/former staff and immediate family members of staff/former staff.

2. Professional courtesy is extended to qualified applicants at no charge.

3. Our office does allow for economic hardship. The patient must sign an agreement form to qualify.

It is not fraud if: 1. Waive entire fee for a referring source if they are part of an entire group that (in written policy) does not take into account their ability to refer. 2. No Out-Of-Pocket Expense is only not fraud under Section 1128 A (a) (5) if the patient for whom the co-payment is waived is a Federal Health Care program beneficiary who is financially needy.

Billing Medicare More Than Non-Medicare Violation to accept insurance only, the exceptions: 1. Hardship Agreement 2. Contractual Obligation with another insurance carrier

Submission of Medicare Claims Our office will comply with following guidelines: 1. File all claims at no charge to patient 2. Provide patient with statement of charges at no charge to include: a. Patient Name b. Date of Service c. Description d. Number of Services provided e. Doctor’s Charge f. Internal Reference Number g. Contact Name and Phone Number

Possible Causes for False or Fictitious Claims 1. Billing for no shows 2. Up coding 3. Unbundling 4. Billing for services not provided

Page | 14 © Copyright 2012 by Dr. John D. Davila. Reproduction of any of this material is strictly prohibited. 5. Bill for non-physician services as if is performed by physician 6. Claims supported by false/fake records 7. Bill for supplies that do not represent a cost to the physician 8. Billing Medicare 1st if Medicare is 2nd 9. Altering medical records 10. Including diagnoses to obtain justification for payment

Possible Omission Violations 1. Not include diagnosis code 2. Not include referring physician 3. Not include outside supplier information 4. Not include physician signature 5. Not include correct CPT code 6. Not include ownership agreements 7. Not include payments made by patient 8. Not include liability or settlement payments

Unlawful Advertising It is unlawful to do the following: Use names, abbreviations, symbols, or emblems of the Social Security Administration, Medicare, Medicaid or any combination of words/symbols that would convey the false impression that the advertised item is endorsed by the named entities. Eg. “Dr. X is a chiropractor approved by both Medicare and Medicaid programs. (Violations may result in $5,000 fine ($25,000 for broadcast) for each violation).

Rental of Space The aggregate space rented must not exceed that which is reasonably necessary to accomplish the commercially reasonable business purpose of the rental.

Enticement/Inducement Please see attached OIG advisory.

A. Informed Consent Policy: 1. The patient’s diagnosis/condition and the proposed treatment, modality, or procedures for correction; 2. The relevant risks and benefits of the proposed treatment, modality, or procedures; 3. Alternative treatment or procedures that are available to the patient and the relative risks, benefits, and uncertainties related to each alternative; 4. The risk and/or benefits of not receiving or undergoing any treatment or procedure; 5. The assessment of the patient’s understanding of the information provided; 6. The acceptance by the patient to undergo the recommended treatment, modality, or procedure; and 7. The patient is competent and the consent is voluntary in order to be valid.

(Informed Consent Form is attached for patient use as directed above.)

Include following example in chart documentation under the PLAN before treatment begins as directed in addition to a signed form:

“Report of Findings and Treatment Plan were presented on XX/XX/XXXX. A benefits and risk assessment was discussed and the patient gave their Informed Consent to treat without questions.”

If questions: paraphrase question(s) and your answer(s).

B. Random Number Generator: Go to the website: http://www.mathgoodies.com/calculators/random_no_custom.html

This is a random number generator that will choose the files to be reviewed and can handle numbers larger than 15,000.

Directions are as follows:

1. Input the #1 2. Input the number of the last file in your system 3. Hit the enter button five times and write down each number

This program will generate 5 random numbers. Your compliance officer should pull these files to reviewed.

The first four links go to the MedScape website. You will need to register for a free account first in order to access the trainings.

Patient Privacy: A Guide for Providers http://www.medscape.org/viewarticle/781892_2

HIPPA and You: Building a Culture of Compliance http://www.medscape.org/viewarticle/762170?src=ocr

Examining Compliance With the HIPAA Privacy Rule (this is a three-page article) http://www.medscape.org/viewarticle/763251?src=ocr

EHRs and HIPAA: Steps for Maintaining the Privacy and Security of Patient Information http://www.medscape.org/viewarticle/821650_2

This link goes to security training games. https://www.healthit.gov/providers-professionals/privacy-security-training- games

I, the undersigned employee with (ENTER PRACTICE NAME) do hereby acknowledge that I have been provided a copy of the Employee Manual and Corporate Compliance Plan (“Plan”). The content of the Plan has been reviewed with me. I understand the content of this Plan and am fully aware that I must comply with these standards or face disciplinary measures, possibly including termination of employment. I agree to report any possible violation to the compliance officer. If I do not report known violations, I assume all responsibility for any damages.

I will cooperate fully with the Compliance Officer, (ENTER COMPLIANCE OFFICER NAME) during the implementation of this Plan. I also will assist Dr. (ENTER DOCTOR’S NAME) during any auditing or monitoring procedures to the fullest.

This acknowledgment form is to be signed after completion of Compliance Plan Review Training and returned, as instructed.

Employee Signature: Printed/Typed Name: Date:

TO THE PATIENT: You have a right as a patient to be informed about your condition and the recommended chiropractic adjustments and other chiropractic procedures to be used so that you may make the decision whether or not to undergo the procedure after knowing the potential risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give or withhold your consent to the procedure.

I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic X- rays, on me (or the patient named below, for whom I am legally responsible) by the Doctor of Chiropractic named below and/or other licensed Doctors of Chiropractic or those working at the clinic or office who now or in the future treat me while employed by, working or associated with, or serving as a backup for the Doctor of Chiropractic named below.

I have had the opportunity to discuss with the Doctor of Chiropractic named below, my diagnosis, the nature and purpose of chiropractic adjustments and other procedures and alternatives. I understand and I am informed that, in the practice of chiropractic there are some risks to exam and treatment including, but not limited to, fractures, disc injuries, strokes, dislocations, sprains and increased symptoms and pain or no improvement of symptoms or pain. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based on the facts then known, is in my best interest. I further acknowledge that no guarantees or assurances have been made to me concerning the results intended from the treatment.

I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions, and all my questions have been answered fully and satisfactorily. By signing below, I consent to the treatment plan. 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.

To be completed by the patient: Print Name: Signature of Patient/or Representative: Date signed:

To be completed by the doctor/staff: Member of doctor’s staff: Date signed:

(Print or Type) PATIENT NAME I.D. NUMBER

STREET ADDRESS

CITY ______STATE______ZIP

For the reasons checked below, I am unable to pay the unreimbursed medical charges due to economic hardship. In addition, I do not have a guardian or other responsible party who can assist me with these expenses.

Please explain: (Select all that apply):

 Unemployed  No insurance  Bankrupt  Dependent on family for support

 Low or fixed income  Student  High medical expenses

 Not covered by state or local welfare program

 Other:

SUPPLEMENTAL INSURANCE (If Applicable)

COMPANY NAME

PATIENT SIGNATURE

******************************************************************

I waive the collection of unreimbursed medical charges on the above mentioned patient/family.

AUTHORIZED SIGNATURE