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Patient Information

Date
Month
Day
Year
Male/ Female
M
F
Birthday
Month
Day
Year
Marital Status

In Case Of Emergency Contact

Insurance

Is patient covered by additional insurance?
Yes
No

I certify that I and/ or my dependents, have insurance coverage with

And assign directly to Dr.Bialecki all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.


The above named doctor may use my health care information and may disclose such information to the above named insurance company(s) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Todays Date
Month
Day
Year

Accident Information

Is condition due to an accident?
Yes
No
Date
Month
Day
Year
Type of accident
To whom have you made a report of your accident?

Patient Condition

Is your condition getting progressively worse?
Type Of Pain
Does it interfere with your
Activities or movements that are painful to perform

Health History

What treatments have you already received for your condition?

Date Of Last

Health History

Place a market on "yes" or "no"to indicate if you have had any of the following

Aids/ HIV
Yes
No
Alcoholism
Yes
No
Allergy Shots
Yes
No
Anemia
Yes
No
Anorexia
Yes
No
Appendicitis
Yes
No
Arthritis
Yes
No
Asthma
Yes
No
Bleeding Disorders
Yes
No
Breast Lump
Yes
No
Bronchitis
Yes
No
Bronchitis
Yes
No
Bullimia
Yes
No
Cancer
Yes
No
Cataracts
Yes
No
Chemical Dependency
Yes
No
Chicken Pox
Yes
No
Diabetes
Yes
No
Emphysema
Yes
No
Epilepsy
Yes
No
Fractures
Yes
No
Glaucoma
Yes
No
Goiter
Yes
No
Gonorrhea
Yes
No
Gout
Yes
No
Heart Disease
Yes
No
Hepatitis
Yes
No
Hernia
Yes
No
Herniated Disk
Yes
No
Herpes
Yes
No
High Blood Pressure
Yes
No
High Cholesterol
Yes
No
High Cholesterol
Yes
No
Kidney Disease
Yes
No
Liver Disease
Yes
No
Measles
Yes
No
Migraines/ Headaches
Yes
No
Miscarriage
Yes
No
Mononucleosis
Yes
No
Multiple Sclerosis
Yes
No
Mumps
Yes
No
Osteoporosis
Yes
No
Pacemaker
Yes
No
Parkinsons Disease
Yes
No
Pinched Nerve
Yes
No
Pneumonia
Yes
No
Polio
Yes
No
Prostate Problem
Yes
No
Prosthesis
Yes
No
Psychiatric Care
Yes
No
Rheumatoid Arthristis
Yes
No
Rheumatic Fever
Yes
No
Scarlet Fever
Yes
No
Sexually Transmitted Disease
Yes
No
Stroke
Yes
No
Suicide Attempt
Yes
No
Thyroid Problems
Yes
No
Tonsilitis
Yes
No
Tuberculosis
Yes
No
Tumors, Growths
Yes
No
Typhoid Fever
Yes
No
Ulcers
Yes
No
Vaginal Infections
Yes
No
Whooping Cough
Yes
No
Exercise
Work Activity
Habits
Are You Pregnant
Yes
No

Informed Consent To Care

You are the decision maker for your health care. Part of our role is to provide you with information to asssist you in making informed choices. This process is often referred to as "informed consent" and involves your understanding and agreement regarding the care we recommend, the benefits and risks associated with the care, alternatives, and the potential effect on your health if you choose not to recieve the care.

We may conduct some diagnostics or examination procedures if indicated. Any examinations or tests conducted will be carefully performed but may be uncomfortable.

Chiropractic care centrally involves what is known as a chiropractic adjustment. There may be additional supportive procedures or recommendations as well. When providing an adjustment, we use our hands or an unstrument to reposition anatomical structures, such as vertebrae. Potential benefits of an adjustment include restoring normal joint motion, reducing swelling and inflammation in a joint, reducing pain in the joint, and improving neurological functioning and overall well-being.

It is important that you understand, as with all health care approaches, results are not guaranteed, and there is no promise to cure. As with all types of health care interventions there are some risks to care, including, but not limited to: muscle spasms, aggravating and/or temporary increase in symptoms, lack of improvmenet of symptoms,burns and/or scarring from electrical stimulation and from hot or cold therapies, including not to limited to hot packs and ice, fractures (broken bones),disc injuries, strokes, dislocations, strains, and sprains. With respect to strokes, there is a rare but serious condition knowns as an "arterial dissection" that typically is caused by a tear in the inner layer of the artery that may cause the development of a thombus (clot) with the potential to lead to a stroke. The best available scientific evidence supports the understanding that chiropractic adjustment does not cause a dissection in a normal, healthy artery. Disease processes, genetic disorders, medications, and vessel abnormalities may cause an artery to be more susceptible to dissection. Strokes cause by arterial dissections have been associated with over 72 everyday activities such as sneezing, driving, and playing tennis.

Arterial dissections occur in 3-4 of every 100,000 people whether they are receiving health care or not. Patients who experience this condition often, but not always, present to their medical doctor or chiropractor with neck pain and headache. Unfortunately a percentage of these patients will experience a stroke.

The reported association between chiropractic visits and stroke is exceedingly rare and is estimated to be related in one in one million to one in two million cervical adjustments. For comparison, the incidence of hospital admission attributed to aspirin use from major GI events of the entire (upper and lower) GI tracts was 1219 events/ per one million persons/ year and risk of death has been estimated as 104 per one million users.

It is also important that you understand there are treatment options available for your condition other than chiropractic procedures. Likely, you have tried many of these approaches already. These options may include, but are not limited to: self-administered care, over-the-counter pain relievers, physical measures and rest,medical care with prescription drugs, physical therapy, bracing, injection and surgery. Lastly, you have the right to second opinion and to secure other opinions about your circumstances and healthy care as you see fit.

I have read, or have had read to me, the above consent. I appreciate that it is not possible to consider every possible complication to care. I have also had an opportunity to ask questions about its content, and by signing below, I agree with the current or futre recommendation to receive chiropractic care as is deemed appropriate for my circumstance. I intend this consent to cover the entire course of care from all providers in this office for my present condition and for any future condition (s) for which I seek chiropractic care from this office.


Date
Month
Day
Year

Statement Of Acknowledgment Of Financial Responsibility Disclaimer Release Of Medical Information Form And Declaration

I understand that I may be financially responsible for any charges incurred at this office, including co pays, deductibles, and charges denied or not covered by my insurance company.


I realize my care may be subject to pre-authorization by the insurance company, and I accpet my responsibility for charges which may not be approved. The insurance company will review any/all documentation submitted by Dr.John M. Bialecki, for review for medical necessity and base their approval/ denial upon this documentation.


I understand that this office agrees to notify me as soon as possbile if a service is not covered and will notify me if my care is not approved by the insurance company. If a treatment plan is approved, this office will make me aware of the number of office visits allowed and the time frame of the authorization. Initial visists may be denied and this may be beyond the offices ability to notify the patient prior to rendering acute care, while waiting for insurance coverage approval. These charges will be the patient's responsibility if denied by the insurance company.


This office may seek payment from you for any services your health insurance plan determines to be not medically necessary.


I have read and understood my obligation for payment for care in the absence of insurance coverage.

Date
Month
Day
Year

Bialecki Chiropractic No Show Policy/ Financial Policy: As of 01/01/23

Our goal is to provide quality care in a timely manner for our patients. We understand unplanned issues can occur. We schedyle our appointments with the doctors to ensure the proper amount of time is spent with each patient. It is important that you are on time for the appointment you are given with Dr.Bialecki.


If your schedyle changes please contact the office and we can arrange a different time for you. We request you give at least 24 hour notice to cancel or reschedyle your appointment. A "No Show" fee of $35-$70 will be applied and charged directly to you depending on the type of appintment it is. The fee at any point can increase without prior notice. The "No Show" fee is not reimbursable by your insurance company. If you are more than 15 minutes late to an appintment, you may be asked to reschedule (which a fee may be applied) or you may have to wait for the next available time that day or another day.


Our office amy decide to termwinate relationship with you if there is consecutive (less than 24 hr notice) cancels and/or no shows.

No Fault & Workers Compensation Plans:

You are responsible for providing Bialecki Chiropractic with the information related to your case so we can properly submit for charges. The fees mandated by New York State No Fault and workers comp will be changed to refelct our contracted fees and you will be responsible for payment. If you have private insurance it may be possible to charge depending on coverage of chiropractic care plan with your insurance.

No Show Policy Agreement- Effective 01/01/23

Bialecki Chiropractic has implemented an update policy. Recent changes in healthy markets and payment processes have altered insurance coverages to shift the cost of care to our patients. Credit card infrormation can be colelcted by front office and kept confidential. If no card on file we may request you pay over the phone any balance before scheduling your next appointment. Bialecki Chiropractic may be authorized to change the account for any appointments missed without the 24 hour notice of cancellation or rescheduling. We want to do our best to service our patients the best we can.

Date
Month
Day
Year

3140 Sheridan Drive, Suite 140, Amherst NY 14226

Tel: 716-240-9365

For Life-Threatening Emergencies Call 911

Email: bialeckichiropracticoffice@gmail,com

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