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(770) 733-1381

Medicare Form

Full Body Rejuvenation Center 3636 Panola Rd. Ste. B Stonecrest, GA 30038, 770.733.1381

First Name*

Last Name*

Advance Beneficiary Notice of Non Coverage (ABN)

NOTE: If Medicare doesn't pay for the Chiropractic Non-Covered Services listed below, you may have to pay.

Medicare does not pay for everything, even some care that you or your health care provider have

good reason to think you need. We expect Medicare may not pay for the Chiropractic Non-Covered Servicesbelow.

Chiropractic Non-Payable Services

Reason Medicare May Not Pay

Estimated Cost Per Service

Chiropractic Examinations

Chiropractic X-rays

Chiropractice Extraspinal Adjustments

Chiropractic Modalities

Chiropractic Weight Loss Program

Chiropractic Massage

These are non-payable services and items by Medicare when delivered and/or ordered by a Doctor of Chiropractic

$20.00 to $200.00

What you need to do now:

Read this notice, so you can make an informed decision about your care.
Ask us any questions that you may have after you finish reading.
Choose an option below about whether to receive the Chiropractic Non-Covered Services listed above.

Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.

OPTIONS: Check only one box. We cannot choose a box for you.

OPTION 1. I want the Chiropractic Non-Covered Services listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn't pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles

OPTION 2. I want the Chiropractic Non-Covered Services listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.

OPTION 3. I don't want the Chiropractic Non-Covered Services listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.

Additional Information: (optional)

This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE(1-800-633-4227/TTY:1-877-486-2048).

Signing below means that you have received and understand this notice. You also receive a copy.

Signature*

Date Signed*

Printed Name*

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According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

Form CMS-R-131 (03/11) Form Approved OMB No. 0938-0566

Informed Consent to Chiropractic Treatment

The nature of chiropractic treatment: The doctor will use his/her hands or a mechanical device in order to move your joints. You may feel a "click" or "pop", such as the noise when a knuckle is "cracked", and you may feel movement of the joint. Various ancillary procedures, such as hot or cold packs, electric muscle stimulation, therapeutic ultrasound or dry hydrotherapy may also be used.

Possible Risks: As with any health care procedure, complications are possible following a chiropractic manipulation. Complications could include fractures of bone, muscular strain, ligamentous sprain, dislocations of joints, or injury to intervertebral discs, nerves or spinal cord. Cerebrovascular injury or stroke could occur upon severe injury to arteries of the neck. A minority of patients may notice stiffness or soreness after the first few days of treatment. The ancillary procedures could produce skin irritation, burns or minor complications.

Probability of risks occurring: The risks of complications due to chiropractic treatment have been described as "rare", about as often as complications are seen from the taking of a single aspirin tablet. The risk of cerebrovascular injury or stroke, has been estimated at one in one million to one in twenty million, and can be even further reduced by screening procedures. The probability of adverse reaction due to ancillary procedures is also considered "rare".

Other treatment options which could be considered may include the following:

• Over-the-counter analgesics. The risks of these medications include irritation to stomach, liver and kidneys, and other side effects in a significant number of cases.

• Medical care, typically anti-inflammatory drugs, tranquilizers, and analgesics. Risks of these drugs include a multitude of undesirable side effects and patient dependence in a significant number of cases.

• Hospitalization in conjunction with medical care adds risk of exposure to virulent communicable disease in a significant number of cases.

• Surgery in conjunction with medical care adds the risks of adverse reaction to anesthesia, as well as an extended convalescent period in a significant number of cases.

Risks of remaining untreated: Delay of treatment allows formation of adhesions, scar tissue and other degenerative changes. These changes can further reduce skeletal mobility, and induce chronic pain cycles. It is quite probable that delay of treatment will complicate the condition and make future rehabilitation more difficult.

Unusual risks: I have had the following unusual risks of my case explained to me.

I have read the explanation above of chiropractic treatment. I have had the opportunity to have any questions answered to my satisfaction. I have fully evaluated the risks and benefits of undergoing treatment. I have freely decided to undergo the recommended treatment and herby give my full consent to treatment.

Signature*

Date Signed*

Printed Name*

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FEMALE X-RAY CONSENT

I understand that there is some danger if I have x-rays and am pregnant. I am satisfied that I understand and I am aware of what those dangers are.

I believe that I (circle one) am not / maybe pregnant.

I am pregnant

I am not pregnant

My last menstrual period began on (date) ___/___/___.

I understand the risk associated with the proposed evaluation and wish to have the x-ray taken at this time.

Signature*

Date Signed*

Printed Name*

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Financial Policy

We want to thank you for choosing Full Body Rejuvenation Center as your chiropractic health care provider. Restoring your health is our foremost objective and passion. Our treatment will always be rendered

solely on the base of need. Our fees comply with the "usual and customary" rates for this region.

REGARDING ALL INSURANCE PATIENTS:

We cannot promise that an insurance company will pay for your care, even if it is pre-authorized. We will submit the bills to your insurance carrier, but will not become involved in disputes between the insured and the insurance company. This courtesy will commence as soon as we are able to confirm coverage for chiropractic services and have the proper, signed insurance forms. Payment of non-covered services balances, co-payments and deductibles are expected at the time of service. We strongly urge you to contact the insurance company to verify your benefits; sometimes incorrect information is provided to us. If an insurance company fails to pay for services within sixty days, the undersigned is responsible for payment. Ultimately, you are responsible for all outstanding balances. If the insurance company erroneously pays directly to the insured, the amount must be forwarded to this office within three days.

1. I elect to have Full Body Rejuvenation Center (FBRC) to bill my insurance company for the covered services I receive from FBRC. In the event of non-payment of any deductible, co-insurance and/or co-payment amount as agreed herein, I will be responsible for any amount unpaid by my insurance company for covered services. I additionally understand that I am responsible in full for the amount of any non-covered services as defined under the terms of my insurance benefit contract. I understand that I am obligated to pay for any non-covered services provided by FBRC. Acceptable forms of payment are cash, check credit and debit cards. Payment is due at the time such services are rendered.

2. Insurance does not pay for all services and items provided in this office. Insurance does not pay for supportive or maintenance chiropractic care delivered by a doctor of chiropractic and you are responsible to pay for these services. You acknowledge that you have been told in advance that supportive or maintenance care is not covered and agree to accept and pay for these services. You have the option to decline these services. Payments for these services are due at the time the services are rendered. I understand that my insurance company will not be billed for these non-covered services.

3. Medicare Patients: Medicare does not pay for all services and items provided in this office. Medicare does not pay for supportive or maintenance chiropractic care. Medicare does not pay for examinations, nonspinal manipulation, manual therapy, therapeutic exercises, neuromuscular reeducation or any other therapeutic procedures including physiotherapies or modalities when delivered by a doctor of chiropractic and you are responsible to pay for these services. You acknowledge that you have been told in advance that supportive or maintenance care is not covered and agree to accept and pay for these services.

AUTOMOBILE ACCIDENTS, PERSONAL INJURY, WORKER'S COMPENSATION AND/OR LITIGATION: If your complaint is the result of an occupational injury, personal injury or automobile accident, or if litigation is pending, please notify us. If an attorney is involved, patients are required to sign a Physician's Lien that will be forwarded to the attorney for signature. If you have medical payments coverage (a.k.a. med-pay) it is our policy to bill this insurance directly and we will provide the attorney with a final statement. Any existing balance left after the med-pay has been exhausted FBRC will be paid from the attorney settlement, third party insurance settlement or the patient at the time of the settlement. Since this settlement will be paid directly to the patient from the attorney or insurance company, it is the patient's responsibility to pay immediately in full the outstanding balance to FBRC. I fully understand that all that all treatment billed through Full Body Rejuvenation Center should be paid first.

1. I understand that I am being treated for injuries sustained in a motor vehicle accident, personal injury and or workman's compensation injury and that failure to keep my appointments may jeopardize the insurance carrier's responsibility for medical costs and/or compensation for pain and suffering

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2. I understand that this office is extending me credit for treatment and that if I miss two (2) office visits without a reasonable excuse all bills may be due immediately.

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3. I understand I will have to pay a onetime administrative fee of $35.00 on my 1st visit for filing fees

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4. I understand that if I sever ties with my attorney before settlement or my attorney will no longer represent my case, all bills may be due immediately

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5. Once released from care, if my case is not settled within six months I will begin making payments of $25.00 a month to this office toward my bill.

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6. If my bill is not paid within 10 days after the settlement, my balance will then be doubled

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7. I further understand that if my account is placed in collection status for non-payment or forwarded to a collection agency that I will be assessed a fee of 33% of my current balance.

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8. No bills and/or records will be released until patient balance has a zero balance, as our office is extending our services as a credit until a final settlement is met. Therefore, all medical records and bills are the property of Full Body Rejuvenation Center, until the patient's balance is paid in full.

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MISSED APPOINTMENTS:

In order to provide you and our other patients with the most optimal spinal care, we request that you follow our guidelines regarding broken and/or cancelled appointments. Please remember that we have reserved appointment times especially for you. Therefore, we request at least 24 hours' notice in order to reschedule your appointment. This will enable us to offer your cancelled time to other patients that desire to get their treatment completed. When you cancel your appointment at the last minute, everyone loses – you, the doctor and other patients that would like to have utilized your appointment time.

In order for you to receive the full benefits of chiropractic care we have put you on a specific treatment schedule. This schedule was designed with your problem in mind. Missed appointments delay the amount of time it takes to correct your problem. For example, if you were prescribed an antibiotic to fight an infection and you were told to take it 4 times a day for 10 days, but instead you only took it whenever you remembered, what do you think the chances are of you getting better? I would say that your chances of getting better would not be that good. Wouldn't you agree?

If you have a scheduled appointment and for some reason you cannot make that appointment, it is our policy that you make up the missed appointment earlier or later that same day or first thing the next day. Remember, you came to us to help you get well. If you do not come in as you are scheduled, you will not achieve this goal.

Please call us as soon as you realize that you must miss an appointment or you may be charged a missed appointment fee. Monday through Thursday the cancellation fee will be $25.00. Fridays, Saturdays, Holidays and After Hours the cancellation fee will be is $50.00. Cancellations must be made during the business hours from 9:30 a.m. -6:30 p.m. you cannot cancel the same day of the appointment.

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Missed appointment fees must be paid before scheduling subsequent appointments. We may request a deposit for future appointments. In fairness to our patients who do pay for service, after reasonable efforts on our part to obtain payment, we will solicit the services of a collection agency if necessary.

I have read this policy and understand that I am financially responsible for all unpaid balances for my care

Patient Acknowledgement:

I have read, understand and agree to the above financial policy. I acknowledge that I am signing this notice voluntarily and that it is not being signed after services have been provided. I have had ample opportunity to ask questions about my financial obligation and other treatment options. I understand I have the right to refuse care and that by signing this form I am fully responsible for all non-covered services. I acknowledge that I have reviewed my coverage options and that I have been told in advance of services rendered what portion of my care I will have to pay for, including non-covered services as described above and agree to make financial arrangements with this office.

Signature*

Date Signed*

Printed Name*

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Pre-Authorization Full Body Rejuvenation Center, LLC

NOTICE OF PRIVACY PRACTICES

ACKNOWLEDGEMENT OF RECEIPT

By signing this form, you acknowledge receipt of the Notice of Privacy Practices of Full Body Rejuvenation Center, LLC, our Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to read it in full.

If you have any questions about our Notice of Privacy Practices, please contact our Compliance Office at:

Full Body Rejuvenation Center

3636 Panola Rd.

Suite B

Stonecrest, GA 30038

(770) 733-1381

Our Notice of Privacy Practices is subject to change. If we change our notice, you may obtain a copy of the revised notice by contacting us at the above address.

I acknowledge receipt of the Notice of Privacy Practices of Full Body Rejuvenation Center, LLC

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Date Signed*

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SSN

ASSIGNMENT AND INSTRUCTION FOR DIRECT PAYMENT TO DOCTOR PRIVATE AND GROUP ACCIDENT AND HEALTH INSURANCE

I hereby instruct and direct the ____________________________ Insurance Company

to pay by check made out and mailed directly to:

Full Body Rejuvenation Center

Dr. Nailah Smith, D.C.

3636 Panola Rd. Suite B Stonecrest, GA 30038

The above named Insurance Company acknowledges the assignment of benefits on file and will pay what is reasonable and customary in the state of GA for medical bills incurred due to the Automobile Accident, WC, or PI caused by their client on stated date:

Date

If my current policy prohibits direct payment to the doctor, then I hereby also instruct and direct you to make out the check to me for the professional or chiropractic expense benefits allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for professional services rendered and mail it to:

Full Body Rejuvenation Center

Dr. Nailah Smith, D.C.

3636 Panola Rd. Suite B Stonecrest, GA 30038

THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY.

This payment will not exceed my indebtedness to the above mentioned Assignee, and I have agreed to pay, in a current manner, any balance of said professional service charges over and above this insurance payment.

A photocopy of this Assignment shall be considered as effective and valid as the original.

I also authorize the release of any information pertaining to my case to any insurance Company, adjuster, or attorney involved in this case.

Signature*

Date Signed*

Printed Name*

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