WARDY WELLNESS CHIROPRACTIC NEW PATIENT INFORMATION

Welcome to our office! To ensure your visit is a pleasant one, here is an outline of the procedures you can expect at out office. If you have any questions, please ask, as there is someone here to assist you. Step 1: Please take time to fill out the new patient information and health history in its entirety to help us better serve you. Due to the fact that we look at you in a more holistic manner, there are very specific reasons as to why we ask you all of the questions that we do. Please do not leave any blanks. Step 2: Once your new patient information and health history is complete, you will meet the doctor for a personal consultation to review your information. Step 3: An appropriate physical, orthopedic, neurological, chiropractic, and kinesiology examination will then be compiled to determine your state of health; and see if our methods of health care are appropriate for your condition(s). You will be advised as to the necessity of additional procedures such as x-rays, laboratory work, or referral to another healthcare professional. If you are in acute pain, some treatment may be performed. Step 4: When you return for your report of findings, on your second visit, the doctor will inform you as to the results of your examination and recommendations for your care. We invite your spouse or those involved in your health care decisions to join you. Step 5: If you are comfortable with the findings and recommendations for care, treatment will begin according to time scheduling. We will refer you to the front desk to arrange an appropriate appointment time. Step 6: Financial arrangements, insurance coverage, and office policies will be covered with you at this time by one of the staff members. Thank you for choosing Wardy Wellness Chiropractic!

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Insurance Information

If we are in network and you would like us to submit your claims directly to your insurance company, please fill out the information below. We will need a copy of your current insurance card. Please carefully read the additional insurance forms you will need to fill out separately from this intake.

Assignment and Release

I certify that I, and/or my dependent(s), have insurance coverage with: Name of Insurance Company: ________________________________ and assign to Dr. Wardy and WWC 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 disclosure such information to the above-named insurance company and their agents. For the purpose of obtaining payment for services and determining insurance for the purpose of benefits payable for related services.

Signature of patient, Parent, Guardian, or Personal Representative _____________________________

Please print name of patient, Parent, Guardian, or Personal Representative ________________________

Date __/__/__ Relationship to Patient ___________________________________________

For your network plans: you will be responsible for the following (according to your plan):

- Co-payments (amount due at time of visit) - Co-insurance (usually a percentage of covered services) - Deductible (as required by insurance policy) - Non-Covered services (Please see attached list)

K Laser Therapy Rapid Release Technology Bemer Therapy EB Bath Infrared Sauna Therapy Barefoot Science plus Rehab Emotional Therapy Protocol Recovery Pumps KAATSU Therapy TCD Clear Neuro-Feedback

- Any additional amount will be determined by the insurance company (e.g. exceeded benefit limit)

Thank you for your understanding and assistance in this matter. WWC and Dr. Wardy recognize and appreciate your willingness to take responsibility for your health and well-being. Please talk to Dr. Wardy if you have any questions or concerns about insurance or anything contained in this form. There are also many options available in choosing health plans that better suit a holistic lifestyle, and may actually save money. Dr. Wardy would be more than willing to discuss these with you. No one has to let the insurance companies dictate the level of care you receive. You are in charge of your own health! Health and Healing is available to everyone, if they choose. We look forward to being a part of your HEALTH care needs.

By signing below I acknowledge that I have read, understand and agree with the insurance billing practices of WWC.

_____________________________________ _____________________

Patient or (Guardian) Signature Date

Consent Agreement and Waiver of Liability for Laboratory Assessment and Nutritional Therapy

Dr. Wardy and Wardy Wellness Center offer laboratory testing for the purpose of assessing the complete metabolic and biochemical terrain of the patient. He also offers nutritional support as part of his individualized treatment plans. This office does not treat symptoms or diagnose diseases. Our focus is to uncover the underlying causes of imbalance. Since a nutritional deficiency may be associated with a specific disease, or it may be the cause of disease, or it may occur as a result of that disease, it is important for you to understand fully that Dr. Wardy uses laboratory analysis and other exam findings to uncover deficiencies and their causes, and not for the diagnosis of a medical condition or illness. Dr. Wardy prescribes vitamins, minerals, bioidentical hormones and therapeutic agents for the sole purpose to aid and support the body to restore proper function and optimal wellness. Instead of focusing on disease and illness, Dr. Wardy uses many modalities to support the body nutritionally, energetically and spiritually, in addition to educating the patient on how to be responsible caregivers to their own bodies. A fully functioning body will by nature, be less likely to manifest disease or illness. This office also uses laborat0ry assessment and nutritional therapy for the prevention of the illness. Functional laboratory evaluations and scientific nutritional therapy are powerful tools for healing imbalances, as well as for prevention of illness. One must be pro-active in their health in order to preserve that health and avoid illness. The laboratory tests and subsequent nutrient recommendations are not meant to diagnose, treat or cure any specific disease. The nutritional recommendations we make based on laboratory tests, physical and clinical findings, history and symptoms, do not constitute treatment for any specific disease. In the nutritional management of a case, we routinely prescribe numerous vitamins, minerals, enzymes, homeopathic, nutraceuticals, bioidentical hormones and other nutritional substances. We do not want you to have any misconceptions about their use in this clinic. In the event that any vitamin, mineral, food or other nutritional substance mentioned above is prescribed or administered in your case, we want you to understand explicitly that its purpose will be for:

1) Improvement of your overall nutritional status 2) Improvement of our metabolism; including absorption, proper utilization and detoxification 3) Improvement of the sense of well-being 4) Possible remission or reduction of pain where present

You must understand that you may not receive any of these benefits, because they do not occur predictably with every patient, and in some cases, they may not occur at all. Also, it is up to you to follow the dietary and/or lifestyle instructions given to you, as this allows the supplements to be utilized properly and be supportive for your healing. Nutritional supplements are an important part of the healing process in that they provide missing or lacking nutrients and can affect metabolic changes in the body which need support. However, it is vital to understand that nutritional supplements do to “: fix” problems or treat symptoms. They are part of a holistic treatment plan which is offered here. Dr. Wardy has obtained advanced training in the use of oral nutrients and has demonstrated competency in this area. Dr. Wardy used on the highest quality nutritional products available. Most of what he prescribes is only available through licensed qualified healthcare practitioners. They are of higher quality, and in many cases, of greater potency than what is available in supermarkets or health food stores. He has researched every nutritional supplement that is offered so that the patients under his care will receive only the highest quality, scientifically formulated, and clinically proven products. Supplements bought elsewhere are often not put through strict manufacturing processes and may not even contain labeled ingredients. All supplements offered through Dr. Wardy are meticulously manufactured by FDA approved, state of the art facilities with advanced raw material testing, production processes, and are verified by third parties as to the purity and potency of each product. Buying a cheaper supplement may only delay the healing process and in some instances may be toxic to your body and exacerbate a condition.

Dr. Wardy has also received advanced training in the administration of nutraceuticals and continues to stay current on the latest research and clinical effectiveness using natural therapeutics. It is important that you follow his instructions to the best of our ability. This office will not be responsible for any adverse reactions or absence of effectivity. In order to improve your health outcome, please implement all suggestions given (including dietary and lifestyle changes). The individualized treatment plan given to you is dependent on all facets working synergistically together. To give a simple analogy, how well does a car move with only two or three wheels? Healing is a partnership and you must be willing to do your part. There are always risks and benefits associated with any therapy. Supplements are prescribed in your case because there has been a clinical need or indication established, or because it may benefit overall health and prevention. However, everybody reacts differently to something new and often when the body is undergoing a shift, it may feel uncomfortable for a while. Please advise Dr. Wardy if any reactions appear, as they may be part of the healing process or signify that a change in dosage or products is needed. Possible unintended reactions include stomach pain, cramps, rashes, headaches, fatigue, allergy, joint pain, vomiting, sweating, increase in body odor, etc. It is also important that you return to our office for scheduled appointments to review the results and interpretation of your tests(s). These tests allow you and Dr. Wardy to better understand y0ur physiology and design an effective and thorough health care plan. Follow up tests are often required as well, in order to ensure that the underlying imbalances re improving with treatment. It is also highly encouraged to acquire yearly laboratory exams so that the baseline tests can be compared and tends observed over time. Knowing your individual, biochemical uniqueness is of great advantage when interpreting laboratory tests. Allowing the Doctor to run your yearly labs can cut down on unnecessary tests and procedures. Return Policy: Once a supplement is purchased, it cannot be returned for any reason, even if the bottle or package is unopened. Once the supplement leaves this office, we can no longer guarantee the potency, purity or condition of the product, how it was handled, stored, etc. (Please keep all supplements in a cool, dry place or refrigerated if indicated). Certain Orthomolecular supplements that we proved have a money back guarantee and you will be notified during purchasing. I have read and understand the above. Under the conditions indicated, I hereby place myself under Dr. Wardy’s care for such advice, prescription, and administration as may appear to be indicated in his professional judgement. You agree to hold Dr. Wardy and Wardy Wellness Center free of any and all liability for any adverse reaction that may result from testing procedures and/or administration of nutraceuticals. Patient (print): ___________________________________ Date: _____________ Signature: ______________________________________ Witness: _______________________________________

Wardy Wellness Center PATIENT CONSENT FOR TREATMENT

(PLEASE READ CAREFULLY BEFORE SIGNING) Informed Consent for Treatment: I voluntarily consent to the rendering of care, including treatment and performance of diagnostic procedures. I understand that I am under the care and supervision of the attending physician and it is the responsibility of the staff to carry out the instructions of such physician(s). I understand the risks associated with chiropractic, therapeutic massage and adjunctive procedures used in this office and agree to the rendering of such care. By signing this, I agree to allow Dr. Wardy to administer the care that he deems necessary and prudent. There are certain “side-effects” associated with chiropractic and therapeutic massage which may include, but not limited to: stiffness, ached or discomfort for several hours or days after the treatment (it is natural for the body to have a period of “re-adjusting” to a new alignment of joints), dizziness, headaches, bruising, aggravation of symptoms, fainting, hematoma, excess energy, sleepiness tiredness and increased thirst. All treatments carry some risk or complications. Please inform the doctor if any symptoms you may experience are severe or worsen. All means of diagnosis and treatment used in this office has validation and general acceptance within the health community. I understand that as with all health-related treatments, there is no guarantee of relief or cure of any disease or condition. I understand that I am free to seek other forms of treatment and that I may withdraw from any treatment at any time. Protected Health Information: By signing this form, I am granting consent to Wardy Wellness Chiropractic (WWC) to use and disclose my protected health information (PHI) for the purposes of treatment, payment and healthcare operations. WWC’s Notice of Privacy Practices provides more detailed information about the use and disclosure of this protected health information. I understand that I have a legal right to review the Notice of Privacy Practices before I sign this consent and WWC encourages me to read it in its entirety. (Please ask the front desk for a copy if you would like). I acknowledge that a copy of the Notice of Privacy Practices was given to me to keep on the initial visit. WWC’s Notice of Privacy Practices is subject to change. If it is changed, I may obtain a copy of the revised notice by telephoning the office at 915-760-4700 or asking in person or in writing for a revised copy. I understand that I have a right to request WWC to restrict how to use and disclose my protected heath information for the purposes of treatment, payment or health care operations. WWC is not required by law to grant my request. However, if WWC does decide to grant my request, WWC is bound by the agreement. I further understand that this consent is valid for seven years and that I have the right to revoke this consent in writing, except to the extent WWC has already used and disclosed my protected health information in reliance to my consent. I also understand that if I choose not to sign this consent, WWC and its affiliates will not treat me. Medicare and Medicaid Consent to Release of Information: I certify that the information given by me in applying for payment under title XVIII and/or Title XI of the SS Act is correct. I authorize any holder of medical or other information about me, to release to the SSA or its intermediary carriers, any information needed for this or related Medicare or Medicaid claim. Verification of Non-Pregnancy: (Female patients only) By signature on this form I do hereby state that to the best of my knowledge, I am not pregnant, nor is pregnancy suspected or confirmed at this particular time. Date of last menstrual period __________ (If applicable). I have read, understand and have all my questions answered and I wish to have WWC and Dr. Wardy treat me at this time. Patient (print): _____________________________________ Date: ______________ Signature: ________________________________________

Understanding Insurance: Your Rights and Responsibilities

(Please take the time to read and understand this document)

The world of insurance has become very complex. This can be even truer in an “alternative” health care environment such as here at Wardy Wellness Center, (WWC). No one wants to spend the time and energy to become an expert on insurance. However, both the patient and the doctor must understand the basics of insurance and how it should be utilized, if at all. The following form will outline what you are required to be responsible for and what the WWC will do with insurance as a service to the patient.

“Sickness” care vs. Health-care

First, please understand that Dr. Wardy is not required to take insurance for services rendered. This is done as a service for some patients so that quality healthcare may be more affordable in some cases. It is also important to understand that most health insurance plans are based on “medical necessity”, meaning that it only covers those services provided to the patient in order to treat a specific illness or injury. As such, a more accurate definition should be “sickness insurance” rather than health insurance, as it does nothing to promote true health or prevention. It only gets activated once you have become sick or injured. This is important because technically your insurance will cover certain chiropractic services only if you are injured or suffering from a medically identifiable condition. It is up to you and your doctor to decide if treatments are injury-related or if they are health-related and holistic. Insurance will cover the injury, but not anything health-promoting.

What is “Holistic Healthcare?”

Wholisitic Healthcare (WH) is a unique approach in health and healing. It is not reactionary like the current model of sickness care, which supports apathy on the part of the patient and medical system. Health is simply thought to be an absence of disease in the current medical environment. Therefore, there is no value placed on prevention or health promotion, let alone early detection and treatment of dis-ease. WH is more preventative, seeking to root out the causes of disease before they fully manifest as an outer “medical” condition. As the old saying goes, an ounce of prevention is worth a pound of cure. WH is also more than just prevention or early detection of dis-ease. It can also be a very effective means of addressing many acute conditions; from sports-related injuries and falls, to more chronic ailments such as diabetes and heart disease. WH treats the patient as an integrated system of many inter-relating components. It recognizes that the whole is much greater than the sum of all these components. WH recognizes the fact that if a person is to bring healing into their lives, they must be supported on many different levels. For example, a broken bone cannot heal correctly unless it is given a balance of rest, exercise, proper nutrients, stimulation and the blockages are removed in the circulatory, lymphatic, connective tissue and meridian systems. WH serves to aid the persons own regenerative and recuperative powers. It is a science, art and philosophy that supports the body’s innate intelligence to heal itself. Another unique aspect of WH is that it is extremely effective at promoting health and wellness. A more accurate definition of health is not just the absence of dis-ease, but also the presence of well-being, energy, stamina, rejuvenation, vitality, balance and harmony. WH is an advocate for true health. Practitioners and patients alike are fortunate to live in an age where health can still be achieved by all who are committed and willing.

Why is WH important in relation to insurance? WH, although a much more effective treatment method, is not accepted into the current medical model of sickness care. WH and traditional medicine are not mutually exclusive, and can actually be very complimentary to one other. However, most insurance plans do not recognize WH and only cover the traditional methods. As a WH practitioner, Dr. Wardy may perform many treatments that, while effective, may not be covered by your insurance even if you are sick or injured. Insurance companies will not pay for preventative or wellness visits either. They call this “elective” or “maintenance” care.

What is covered at the WWC?

Dr. Wardy bills insurance under his chiropractic license. Only those treatments that the insurance company considers chiropractic services will be covered. This usually means the manipulation (adjustment) of the spine and extremities, soft tissue work, and in some cases infrared, ultrasound, application of hot/cold and some therapeutic exercise instruction. This is not a complete list of covered services and represents only those commonly considered covered chiropractic treatments. Of these covered services, you may still be responsible for all or part of these services depending upon copay, deductible and limitation of benefits (see your specific health plan contract).

Do I have to use insurance for my treatments at WWC, even if I have it?

You may choose not to use your insurance, even if it covers chiropractic. You must sign a waiver stating that you wish to relinquish your insurance privileges knowing that some benefits may be allowed. There may be some advantages to paying out of pocket for wholistic treatments. Many do not want anything to go on their health record for various reasons. If your insurance is utilized, there will be a permanent record of some injury or illness that may be used against you in the future, or cause your premiums to increase. Also, some simply do not want to go through the hassle of dealing with insurance companies. Others may have high deductibles and do not wish to pay WWC the extra billing fees required to bill insurance. The choice is yours. Dr. Wardy will be happy to discuss your options and what fits best for your situation.

What if I choose to utilize my insurance?

There will be a $40 initial set-up fee in order to allow us to bill your insurance, and a $20 fee if there is a change to a different insurance company later on. In addition, there will be a$10 laboratory billing fee if laboratory tests are to be billed. Much effort and resources goes into billing your insurance company. Sophisticated software, billing services, computers, hours of labor and administrative fees that WWC must pay are all required in order to be involved with the insurance industry. The WWC must be able to submit claims, receive your benefit statements, keep accurate records of accounts, keep your information private and protected, and spend a seemingly unending amount of time correcting denials, delays and mistakes made by insurance companies in processing claims. This is mentioned here because many patients may not understand what it takes to deal with insurance companies and their tactics.

Patient rights and responsibilities with insurance.

Every insurance plan is different. There are a multitude of insurance companies and even more plans to choose from. If it has been determined that you are eligible for benefits, WWC will bill according to your insurance agreement. Please note that Dr. Wardy is considered an In-Network Physician for a few plans only (currently BCBS, Aetna, and a few others). If Dr. Wardy is an in-network physician, then WWC will bill your insurance directly for covered services and will be reimbursed at contracted rates agreed upon by physician and insurance company (these are often reduced reimbursement rates to the physician). You will not be billed for any reduced rate differences. If Dr. Wardy is out-of network, then you will be responsible for full payment at time of visit. Please call your insurance company to see if you have any out-of-network benefits for chiropractic. If so, WWC may bill your insurance directly if you wish, or provide you with a bill that you may submit. Reimbursement (if any) will be sent directly to you from the insurance company.

Thank you for your understanding and assistance in this matter. WWC and Dr. Wardy recognize and appreciate your willingness to take responsibility for your health and well-being. Please talk to Dr. Wardy if you have any questions or concerns about insurance or anything contained in this form. There are also many options available in choosing health plans that better suit a holistic lifestyle, and may actually save you money. Dr. Wardy would be more than willing to discuss these with you. No one has to let the insurance companies dictate the level of care you receive. You are in charge of your own health! Health and Healing is available to everyone, if they choose. We look forward to being a part of your HEALTH care needs.

By signing below I acknowledge that I have read, understand and agree with the insurance billing practices of WWC. _______________________________________ ___________________ Patient (or Guardian) Signature Date