Notice of Informed Consent
California Code of Regulations, Title 16, Div. 4, Article 2, Section 319.1 requires your acknowledgement of proposed risks relating to care at this office in the form of an informed consent by signature on intake form.
The procedures used in this office require interactive participation defined as skin surface reflexes, hard and soft tissue manipulation. Soft tissues manipulation sites are on the torso, pelvis, and face. I am active during the treatment, moving quickly from one place on the body to another, and for some individuals sensitive areas may be brushed, touched or pushed or pressured. Kindly be assured that there is no intention ever to violate personal boundaries, yet these vary considerably from one person to another. If ever you feel uncomfortable at any time during a treatment session, please do not hesitate to speak up and ask me to pause so I hear and understand what you need.
Hard tissue manipulation (chiropractic adjustments) may be incorporated infrequently in the form of spinal, cranial and or extremity manipulation. When these manipulation procedures are employed you will be verbally notified. As a general rule, manipulation steps are incorporated to stimulate reflexes within bony and adjacent soft tissue structures that stimulate involved neural pathways. i.e. simply stated act as resetting a circuit breaker.
Soft tissue manipulation steps are a combination of rubbing, stretching, and pinching type activities. Steps that are known to cause brief physical discomfort include stimulation of internal jaw muscles. This step is frequently employed on every visit. A clean finger cot is always used for this procedure. If you have a latex sensitivity please let me know
Signature ____________________________________________ Date: _______________
I have verbally reviewed consent with patient. _______________ Date: _______________
Dr. Mitchell Corwin, D.C It is the goal of this office to provide health care in a cost effective and efficient manner. To accomplish this, we utilize minimal staff and ancillary services. If you miss an appointment or fail to give us appropriate cancellation notice of 48 hours, there may be a fee, typically half the session charge. It is your responsibility to call and reschedule as well as to schedule preventive /follow up visit(s), commonly every 4-6 months.
Office Policy
Office Policy
Office visits are scheduled in one hour visits. Extended visits may run 90 minutes or longer if necessary to accommodate anyone traveling a long distance.
Missed Appointments are not tolerated as I have allocated 1 hour for your visit.
Appointment failure without a good reason:
1st offense [an excuse is need] ...2nd [a better excuse is need]...3rd your file will be misplaced!
Last minute cancellations, please call or text Dr. Corwin's cell (510) 367-8475
instead of the office number (510-845-3246).
Cancellation policy: Please try to call within 48 hours to best allow us to offer your visit time to someone else.
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This office will take every precaution to protect your health information and privacy however; there can be an incidental disclosure of phone messages due to an open front desk / common waiting room. Please note my computer that maintains patient information and billing is located at my home and is of vintage type that is not connected to the Internet.
Please note that many insurance carriers request doctors files (i.e. doctors progress notes and the intake form you filled out) so include only the information you want others to peruse.
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Verbal or written permission will be sought before communicating relevant health information to other health care providers or family members.
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Billing and periodic statements will be provide:
- As a courtesy, I will submit an itemized claim form to your insurance carrier.
If I have incomplete information, the claim form will be mailed to you to complete and forward to your carrier.
- All medicare billing will be completed as required by law
- You may also request a summary statement for taxes or medical savings account at anytime. Feel free to email me with that request.
Advanced Beneficiary Notice
Advanced Beneficiary Notice (ABN) is terminology used by Medicare to inform the public /patients of non-covered services often provided by licensed healthcare practitioners.
Advanced Beneficiary Notice purpose is to allow potential patients the opportunity to make informed decisions about the services of healthcare one is requesting. Medicare has strict guidelines which restrict what type of services and diagnosis that I can make as a licensed Chiropractor. To that extent, you are encouraged to consider (by the rules of Medicare) to consult a physician whom will provide only medicare approved procedures thus reducing ones out-of-pocket expenses to a small co-payment or a pre-approved substantially reduced medicare office visit fee.
The healthcare provided at this office are generally non-approved services, thus medicare often will reject part or all of the submitted bill. Additionally Dr. Corwin has chosen not to be an enrolled medicare provider thus I do not except co-payments and medicare assignment.
Dr. Corwin will submit a claim to Medicare as required by law. If you have secondary insurance, medicare will forward the claim to the secondary carrier.
If your medicare has been assigned to an HMO (Kaiser, Health Net etc.) then none of the above is relevant and medicare can not be billed by any out of network provider.
Please note that your choice to receive care with Dr. Corwin releases your rights to appeal to medicare for fee reimbursement(s) of rejected billing(s) or request a reimbursement of non-covered services from the provider.
Additionally it is understood that you are responsible for all fees incurred at this office. If medicare or your secondary insurance mistakenly provides a benefit reimbursement to me, the amount will be refunded promptly.
If you have any questions or concerns, please let me know. Email Dr. Corwin
Office Visit Fees
- Initial Office Visit Fee: $155 ...Consultation, Evaluation and Treatment (60 min.)
- Follow Up Visits: $155 ...Generally scheduled weekly (60 min appointment)
- *Long Term Patients may have a lower Fee Schedule.
Dr. Corwin is not a preferred provider for an insurance carrier nor an enrolled Medicare Provider.
If Insurance information is provided, I will complete and mail it to the appropriate carrier.
Medicare billing statements will be processed as required by law. Please note as described directly above in the Medicare Advanced Beneficiary Notice of Non-Coverage, medicare covers on a small fraction of the services.
Payment is expected at the time of service.
*Whatever fee schedule one starts at will remain the same throughout your active care.
If finances are a challenge, you may plead your case and I may allow a reduced fee of $125 representing our prior fee schedule of years ago. > bonus offer <
Bonus Offer
If you are able make an appointment on your birthday, the visit is free!
If your birthday does not fall on a day during my work week, better luck next year!
MISSION STATEMENT
My purpose is to address your health concerns swiftly and cost effectively. To accomplish this, I work in 60 minute appointments. This time frame allows me to accomplish the necessary work to minimize recidivism and maximize response to care. My goal is to identify the causative factor(s) and return your body, mind and spirit to optimal health.
Please note:
Thru this past Covid year and probably thru most of 2021-23,
I will be working without office assistance and all phone calls will go directly to answering machine.
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Last minute cancellations, please call or text
Dr. Corwin's Cell
(510) 367-8475
