• Maimonides Chiropractic
  • Acupuncture Patients Start Here!
    Follow these steps to complete your paperwork in less than 15 minutes:

    Step 1: Provide Your Contact Information
    Step 2: Tell us the Reason for Your Visit
    Step 3: Answer some Health History Questions
    Step 4: Read Important Information about Your Privacy (HIPAA)
    Step 5: Sign the Consent to Treatment Page

    Click the Start button to begin.

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  • Step 1: Provide Your Contact Information

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  • Step 2: Tell us the Reason for Your Visit


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  • Step 3: Answer some Health History Questions

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  • Symptom Finder - A Fun Diagnostic Tool!

    Your symptoms tell us a lot about you! Please take just a few more minutes to go section by section and check off the symptoms you've been experiencing.

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  • Step 4: Read Important Information about your Privacy (HIPAA)

    Maimonides Chiropractic is committed to maintaining the privacy of your protected health information (“PHI”), which includes information about your medical condition and the care and treatment you receive from our practice and other health care providers. As a patient of Maimonides Chiropractic, your PHI may be used and disclosed to third parties for purposes of your care, payment for your care, health care operations of the practice, and for other purposes permitted or required by law.

    Maimonides Chiropractic may use and/or disclose your PHI for purposes related to your care, payment for your care, and health care operations of the practice. The following are examples of the types of uses and/or disclosures of your PHI that may occur. These examples are not meant to include all possible types of use and/or disclosure.

    Care – In order to provide care to you, Maimonides Chiropractic will provide your PHI to those health care professionals directly involved in your care so they may understand your medical condition and needs and provide advice or treatment. For example, your physician may need to know how your condition is responding to the treatment provided by Maimonides Chiropractic.

    Payment – In order to get paid for some or all of the health care provided by Maimonides Chiropractic, we may provide your PHI, directly or through a billing service, to appropriate third party payers, pursuant to their billing and payment requirements. For example, we may need to provide your health insurance carrier with information about health care services you received from the Practice so the Practice may be properly reimbursed.

    Health Care Operations – In order for Maimonides Chiropractic to operate in accordance with applicable law and insurance requirements and in order that we may provide quality and efficient care, it may be necessary for us to compile, use and/or disclose your PHI. For example, we may use your PHI in order to evaluate the performance of our personnel in providing care to you.

    Your name, address, telephone number and your healthcare records may be used to contact you regarding appointment reminders, information about alternatives to your present care or for other health-related information that may be of interest to you. If you are not at home to receive an appointment reminder, a message may be left on your answering machine.

    You have the right to inspect or obtain a copy of the information we will use for these purposes. You also have the right to refuse to provide authorization for this office to contact you regarding these matters. If you do not provide us with this authorization, it will NOT affect the care provided to you or the reimbursement avenues associated with your care.

    Under federal law, we are also permitted and/or required to use or disclose your health information without your consent or authorization in these circumstances: if we are providing healthcare services to you based on the orders of another healthcare provider; if we provide healthcare services to you in an emergency; if we are required by law to provide care to you and we are unable to obtain your consent after attempting to do so; if there are substantial barriers to communicating with you but in our professional judgment we believe that you intend for us to provide care; if we are ordered by the courts or another appropriate agency. Any use or disclosure of your protected health information other than as outlined above will only be made upon your written authorization.

    A complete copy of our HIPAA Notice of Privacy Practices is available on our website at www.MaimonidesChiropractic.com.

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  • Step 5: Sign the Consent to Treatment Page

    This section contains important information about payments, insurance, scheduling, and cancellations.

    Payments and Insurance Assignment

    Our office is in-network with Blue Cross-Blue Shield and Carefirst PPO programs and Medicare ONLY. We are out-of-network with all other companies effective September 1, 2014.

    If we are in network with your plan, your co-pay, co-insurance, or allowed amount is due at the time of services are rendered as dictated by your policy. We will file claims with your insurance company after each visit and assist you in every way we can.

    If we are out-of-network with your insurance company, we ask that you make payment in full at the time of each visit. After your visit, we will be pleased to email you a superbill which contains all the information necessary for you to submit for reimbursement from your insurance company. We cannot guarantee how your insurance company will behave or pay. We will not enter into any disputes with your company because the relationship is between you and your insurance company alone.

    If you will not be using insurance at all, please make sure to ask about the Preferred Chiropractic Doctor program (www.youbewell2.com) which offers a cash discount on our services and products. This program has been a favorite of our military families for over a decade but you do not have to be a military family to benefit!

  • Cancellations and Rescheduling

    When life happens and you must reschedule your appointment, we are happy to help. Please help us help you.

    If something comes up, call us within 24 hours of your visit to give us notice so that we may schedule you for the soonest next available appointment. In this way we may offer your time to someone who may really need help.

    Missed Appointments

    The first time a scheduled appointment is missed without proper notice, you will not be charged.  Everyone forgets sometimes.

    The second time a scheduled appointment is missed without proper notice, our office will charge the patient 50% of the entire value of the visit missed.

    The third time this occurs, our office reserves the right to charge the patient for the value of the entire visit before scheduling future appointments.

    After this, our office reserves the right to reconsider our ability to schedule the patient in the future.

  • Informed Consent for for Acupuncture and Oriental Medical Treatment

    I hereby request and consent to be treated with acupuncture and other procedures within the scope of the practice of Oriental Medicine. I understand that this treatment will be performed by Dr. Erica Statman and/or other Doctors of Chiropractic who now or in the future may treat me while employed by, working with or associated with Maimonides Chiropractic.

    There are some risks to treatment, including but not limited to some bruising of the skin and/or slight bleeding. If moxibustion or heat therapies are used there is a risk of burn and/or scarring.  The risk of infection is small when all needles are sterile.  Needles are considered sterile when they are either disposable or are autoclaved according to applicable state legal requirements.  To maintain the highest standards of health and safety we only use disposable needles in the office.

    I understand that it is strongly recommended to eat a light snack or meal and stay hydrated prior to treatment to avoid possible lightheadedness.

    I have had an opportunity to discuss with the Doctor the nature and purpose of Acupuncture and Oriental Medicine. I understand that results are not implied nor guaranteed.

    I DO NOT EXPECT THE DOCTOR TO BE ABLE TO ANTICIPATE AND EXPLAIN ALL RISKS AND COMPLICATIONS.  I WISH TO RELY ON THE DOCTOR TO EXERCISE JUDGMENT WHICH THE DOCTOR FEELS IS IN MY BEST INTEREST, BASED UPON THE FACTS THEN KNOWN, DURING THE COURSE OF THE PROCEDURE.

    I UNDERSTAND THAT I HAVE THE CHOICE TO ACCEPT OR REJECT THE PROPOSED DIAGNOSTIC PROCEDURE OR TREATMENT, OR ANY PART OF IT, BEFORE OR DURING THE DIAGNOSIS OR TREATMENT.

    I understand that the doctor is not providing Western (allopathic) medical care, and that I should look to my Western primary care practitioner (i.e., M.D.) for those services and for routine check-ups.

    I have read, or have had read to me, the above consent.  I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures.  I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

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