Patient Information and Consent

Patient Information and Consent

Welcome and thank you for considering The Neural Connection Professional Corporation (“The Company” or “The Neural Connection” or “Provider”) for your health care needs (“You”, “Patient”, “Client”). This document contains important information about our professional services and business policies.

As with any healthcare experience, there are terms and conditions that apply to your care at The Neural Connection. We’ll be as brief as our attorney will allow. The main thing to remember is that by using our services, you agree to the terms set forth below along with the Provider’s Privacy Policy (www.theneuralconnection.com/notice-of-privacy-practices) and Terms of Use (www.theneuralconnection.com/terms-of-use). Services shall not be rendered if you do not accept this Agreement.

Chiropractors and Healthcare Practitioners – Agents of Company, Provider

The chiropractor is engaged in private practice providing health care services to patients directly through The Neural Connection Professional Corporation. The chiropractor is properly licensed under Minnesota law. The chiropractor and all other healthcare practitioners are acting in their capacities under The Neural Connection Professional Corporation, and nowhere in this agreement is the chiropractor or all other healthcare practitioners acting in their individual capacities.

Appointments

Appointments are made by calling 952-898-4450 during the normal business hours Monday through Friday; 8am-5pm, or by visiting: https://theneuralconnection.janeapp.com. Please call to cancel or reschedule at least 24 hours in advance, or you will be charged for the missed appointment. Third-party payments will not usually cover or reimburse for missed appointments. If you are late, you will be charged for the full amount of the appointment and there will be no pro-rating of the fee. If the Provider has to cancel the appointment, you will be entitled to a refund if payment has already been tendered.

Length of Visits

The initial intake and evaluative session is normally scheduled for one (1) hour and may run longer depending on the testing or assessments a patient is asked to complete. Once the evaluation process is completed, health sessions are 15 minutes in length unless otherwise specified.

Payment for Services

A fee schedule may be requested in person at the address listed above.

These fees are subject to change upon thirty (30) days’ prior notice to you. If you are unable to pay, or are not willing to pay, the higher fee after receipt of notice, services may be terminated and you may be given referrals to other competent providers. You shall pay The Neural Connection $300/hour to fill out administrative paperwork. The Provider will look to you for full payment of your account, and you will be responsible for payment of all charges. We currently do not accept insurance. You may pursue reimbursement on your own, and we will provide necessary documents upon request. The Neural Connection reserves the right to discharge you at anytime, without notice.

Any charges incurred during the visit shall be paid at the end of the visit. You shall pay The Neural Connection when the services are rendered. Your financial information will be maintained on file as a service to you. Your patient financial responsibility will be charged each month using your financial information on file, unless you give proper notice to cancel your consent.

The Neural Connection currently takes credit cards, debit cards and checks. The Neural Connection reserves the right to not accept checks from you if any of your checks are returned due to insufficient funds. The first time a check is not accepted, you shall pay the bank fee and you will be required to pre-pay for all services thereafter.

Other payment arrangements may be discussed upon request, but it is explicitly understood that all financial responsibility remains with you as the client. In the event that a balance is carried on your account after 30 days without notification, The Neural Connection reserves the right to charge the outstanding amount to the credit card on file as per the payment information provided by you. This process will occur without additional notification, and you are responsible for ensuring the availability of funds on the designated credit card for timely settlement of any outstanding balances.

Although it is the goal of the Provider to protect the confidentiality of your records, there may be times when disclosure of your records or testimony will be compelled by law. Confidentiality and exceptions to confidentiality are discussed in the Notice of Privacy Practices and HIPAA Consent form.

Risks of Health Services and Limitation of Liability

The success of our work together depends on the quality of the efforts on both our parts, and the realization that you are responsible for lifestyle choices/changes that may result from our health services. There are no guarantees in providing health services and the Provider and its agents do not make any guarantees with this agreement. You assume the risk of health services by reading and signing this form. The Provider is not liable for any adverse reactions to treatment or providing health services. THE PROVIDER’S AGGREGATE LIABILITY SHALL, IN ALL CASES, BE LIMITED TO THE AMOUNT PAID BY YOU TO BE A PARTICIPATING PATIENT OF THE PROVIDER. The Provider may take any reasonable action necessary while providing health services when there is a dangerous circumstance, as determined by the Provider. The Provider does not treat chronic pain. The Provider will not fill out any FMLA, Disability or other non-Provider forms on the first visit.

After-Hours Emergencies

Please know that the Provider does not provide twenty-four (24) hour crisis or emergency health services. Should you experience an emergency necessitating immediate health attention, immediately call 911 or if you are able to safely transport yourself, go to the nearest hospital emergency room for assistance.

Contacting Your Provider

The office number 952-898-4450 is answered by voicemail that the Provider will monitor from time to time throughout the day. The Provider’s health professionals are typically in the office during normal business hours, but will not take calls when with a patient. A reasonable effort will be made to return any call made during normal business hours on the same day it is received. Messages left after hours will normally be returned the next business day. Please inform your chiropractor of times when you will be available to optimize communications.

The Provider may use and respond to E-mail and text messages to communicate. We may send e-mails related to your treatment or health services as electronic communications which are not completely secure and confidential. Any electronic transmissions of information by you are retained in the logs of your service providers. While it is unlikely that someone will be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the service providers. You should know that any e-mails or any communications sent via Facebook, online and specifically the website www.theneuralconnection.com are not secure and you assume the risks of the insecure transmission.

Health Professional’s Incapacity or Death

You acknowledge that, in the event the health professional serving you becomes incapacitated or dies, it will become necessary for another health professional to take possession of your file and records. By signing this information and consent form below, you give consent to allowing another licensed health professional selected by the Provider to take possession of your file and records and provide you with copies upon request, or to deliver them to a health professional of your choice. The Provider will select a successor health professional within a reasonable time and will notify the appointed health professional. You specifically consent to the Provider and any designated health professional to take possession of your file and records during this transition.

Audio and Video Recordings

You acknowledge and, by signing this information and consent form below, agree that neither you nor the Provider will record any part of your sessions unless you and the Provider mutually agree in writing that the session may be recorded. You further acknowledge that the Provider objects to you recording any portion of your sessions without the Provider’s written consent. You expressly agree that audio and video recordings used for security purposes are not part of health services, and are therefore not protected by confidentiality or any other provisions under this agreement.

Defamation

By signing this intake and consent form below you agree that you will not make defamatory comments about the Provider or its agents to others or to post defamatory commentary about the Provider on any website or social media site. In the event that defamatory remarks about the Provider or its agents are made by you, or others acting in concert with you, you further consent by signing this intake and consent form below to allowing the Provider and its agents to use confidential information necessary to rebut or defend against, or prosecute claims for, the defamation.

Cooperation of Patient

You shall keep the Provider advised of any changes of address, phone number, contact information, or business affiliation during the time period which the Provider’s services are required. You shall comply with all reasonable requests of the Provider in connection with your treatment. The Provider may set boundaries including forms of patient interactions and communication including ceasing to provide services to you for good cause, including without limitation: your refusal to comply with treatment recommendations, the Provider is uncomfortable working with you, or your failure to timely pay fees in accordance with this Patient Information and Consent Form, subject to the professional responsibility requirements to which the health professionals are subject.

Privacy and Security of Communications

All electronic communications between you and the Provider will be transmitted using reasonable measures to ensure confidentiality. You will be responsible to secure and protect the functionality, integrity, and privacy of your hardware, files, and communication. Password protection for accessing your hardware and files is recommended. If others will be accessing the same computer, be aware that programs exist that copy every keystroke you make.

Legal

This Agreement shall be construed in accordance with, and governed by, the laws of the State of Minnesota as applied to contracts that are executed and performed entirely in Minnesota. The exclusive venue for any court proceeding based on or arising out of this Agreement shall be Hennepin County or Ramsey County, Minnesota. The parties agree to attempt to resolve any dispute, claim or controversy arising out of or relating to this Agreement by arbitration, which shall be conducted under the then current arbitration procedures of the American Arbitration Association any other procedure upon which the parties may agree. The parties further agree that their respective good faith participation in arbitration is a condition precedent to pursuing any other available legal or equitable remedy, including litigation, arbitration or other dispute resolution procedures. If any legal action or any arbitration or other proceeding is brought for the enforcement of this Agreement, or because of an alleged dispute, breach, default or misrepresentation in connection with any of the provisions of this Agreement, the successful or prevailing party or parties shall be entitled to recover reasonable attorneys’ fees and other costs incurred in that action or proceeding, in addition to any other relief to which it or they may be entitled. Electronic copies of this Agreement and electronic signatures have full affect and legal validity.