Consultations

BASIC INFORMATION

INSURED'S INFORMATION

INSURANCE INFORMATION

INSURANCE INFORMATION

SECONDARY INSURANCE INFORMATION

CONSENT TO TREATMENT
I do hereby seek and consent to assessment, examination, AND treatment by Vogelfanger & Struble Clinic and/or any of its associates. I understand that developing a treatment plan and regularly reviewing my progress toward meeting my treatments goals is in my best interest. I agree to participate actively in this process. ASSIGNMENT OF BENEFITS
I authorize payment directly to Vogelfanger & Struble Clinic PLLC of any benefits payable under my insurance policy for the indicated services.

PATIENT RIGHTS AND RESPONSIBILITIES Patient Rights Patients have the right to be treated with dignity and respect.
Patients have the right to fair treatment regardless of race, religion, gender, sexual orientation, ethnicity, age, disability, or source of payment.
Patients have the right to have their treatment and other patient information kept private. Only when required by law will information and records be released without patient permission.
Patients have the right to access care in a timely fashion.
Patients have the right to know about treatment options. This is regardless of cost or. coverage by patient's benefit plan.
Patients have the right to participate in developing a plan of care.
Patients have the right to get information in a language the patient can understand.
Patients have a right to receive a clear explanation of their progress, condition, and treatment options.
Patients have the right to get information about their insurance plan, practitioners available, services available, and the insurance company's role in the treatment process.
Patients have the right to information about clinical guidelines used in providing and managing patient care.
Patients have the right to ask the provider about provider's work history and training.
Patients have the right to give input on the patient rights and responsibilities policy,
Patients have the right to know about advocacy, community, and prevention services. Patients have the right to freely file a complaint or appeal to their insurance company and to learn how to do so.
Patient have the right to know their rights and responsibilities in the treatment process.
Patients have the right to receive services that will not jeopardize employment. Patients have the right to identify certain preferences in selecting a provider.
Patient Responsibilities Patients have the responsibility to treat those giving them care with dignity and respect.
Patients have the responsibility to give the providers the information they need. This is so providers can deliver the best possible care.
Patients have the responsibility to ask questions about their care. This is to help them understand their care.
Patients have the responsibility to follow the treatment plan. The plan of care is to be developed and agreed upon by the patient and provider.
Patients have the responsibility to follow the agreed upon therapy and medication plan.
Patients have the responsibility to tell their provider and primary care physician about medication changes, including medication given to them by others.
Patients have the responsibility to keep their appointments. Patients should call their provider as soon as they know they need to cancel appointments.
Patients have the responsibility to let their provider know when the treatment plan is not working for them.
Patients have the responsibility to let their provider know about problems paying fees.
Patients have the responsibility to report abuse and fraud.
Patients have the responsibility to openly report concerns about the quality of care they receive.