Register Form

­ARBITRATION AGREEMENT AND INFORMED CONSENT
Article 1: It is understood that any dispute as to medical malpractice, that is as to  whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. 

Article 2: All Claims Must be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims may arise out of or relate to treatment or services provided by the health care provider including any heirs or past, present or future spouse(s) of the patient in relation to all claims, including loss of consortium. This agreement is also intended to bind any children of the patient whether born or unborn at the time of the occurrence giving rise to any claim. This agreement is intended to bind the patient and the health care provider and/or other licensed health care providers or preceptorship interns who now or in the future treat the patient while employed by, working or associated with or serving as back-up for the health care provider, including those working at the health care provider?s clinic or office or any other clinic or office, whether signatories to this form or not. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the health care provider, and/or the health care provider?s associates, association, corporation, partnership, employees, agents and estate, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. This agreement is intended to create an open book account unless and until revoked. 

Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days thereafter. Each party to the arbitration shall pay such party?s pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees, witness fees or other expenses incurred by a party for such party?s own benefit. 

Article 4: General Provisions: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one processing. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable California statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. 

Article 5: Revocation: This agreement may be revoked by written notice delivered to the health care provider within 30 days of signature and if not revoked will govern all professional services received by the patient and all other disputes between the parties.

Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment) patient should initial below. Effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this arbitration agreement. By my signature below, I acknowledge that I have received a copy. ***NOT

ASSIGNMENT OF INSURANCE PAYMENT PAID TO PATIENT ASSIGNMENT OF INSURANCE PAYMENT PAID DIRECTLY TO PATIENT This is an agreement that any payment from your insurance company that is sent directly to the patient should be sent to Dr. Michael A. Sanchez. It is the patient's responsibility to sign over the check and forward it to Dr. Michael A. Sanchez within 3 days of receiving the payment. 
Please forward to: Up 2 Speed Sports Performance and Therapy 7071 Commerce Circle, Suite A Pleasanton, CA 94588 
1) I agree that I, the undersigned, am responsible to send payment to Dr. Michael A. Sanchez.
2) I hereby agree to send payment within 3 days of receiving payment from my insurance company 2. Date

HIPAA Form PATIENT PRIVACY ACT This notice describes how chiropractic and medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. In the course of your case as a patient with Up 2 Speed Sports Performance and Therapy we may use or disclose personal information about you in the following ways: -Your protected health information, including your clinical records, may be disclosed to another health provider or hospital if it is necessary to refer you for further diagnosis, assessment, or treatment. -Your health care records as well as your billing records may be disclosed to another party, such as an insurance carrier, an HMO, a PPO, or your employer, if they are or may be responsible for payment of services provided to you. -Your name, address, phone number, and your health records may be used to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information that may be of interest to you. You have the right to request restrictions on our use of your protected health information for treatment, payment, or operation purposes. Such requests are not automatic and require the agreement of this office. I understand that this office uses an open treatment area and I may be treated in front on other patients. I may request a private room to be used for my treatment. Health information or information about my case may be discussed in front of the other chiropractors in the office or the office receptionist. A private room can be requested to discuss any health information about yourself. If you are not at home to receive an appointment reminder or other related information, a message may be left on your answering machine or with a person in your household. You have the right to confidential communications and to request restrictions relative to such contacts. You also have the right to be contacted by alternative means or at alternative locations. We are permitted/may be required to use or disclose your health information without your authorization in these following circumstances: -If we provide health care services to you in an emergency. -If we are required by law to provide care to 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 judgement, we believe that you intend for us to provide care. -If we are ordered by courts or another appropriate agency. You have the right to receive an accounting of any such disclosures made by this office. Any use or disclosure of your protected health information, other than as outlined above, will only be made upon your written authorization. If you provide an authorization for release of information you have the right to revoke that authorization at a later date.
PRIVACY NOTICE Information that we use or disclose based on this privacy notice may be subject to re-disclosure by the person to whom we provided the information and may no longer be protected by federal privacy rules. We normally provide information about your health to you in person at the time you receive chiropractic care from us. We may also mail information to you regarding your health care or about the status of your account. If you would like to receive this information in a specific form, please advise us in writing as to your preference. You have the right to inspect and/or copy your health information for as long as the information remains in our files. In addition, you have the right to request an amendment to your health information. Request to inspect, copy, or amend your health related information should be provided to us in writing. We are required by state and federal law to maintain the privacy of your patient file and health protected information therein. We are also required to provide you with this notice of our privacy practices with respect to your health information. We are further required by law to abide by the terms of this notice while it is in effect. If yo

CANCELLATION POLICY/NO SHOW POLICY
We understand that there are times when you must miss and appointment due to emergencies or obligations for work or family. However, when you do not call to cancel and appointment, you may be preventing another patient from getting much needed treatment. Conversely, the situation may arise where another patient fails to cancel and we are unable to schedule you for a visit, due to a seemingly full appointment book.
1) I, the undersigned, have read and fully understand the above agreement.
By signing this form, I give permission to Up 2 Speed Sports Performance and Therapy to charge me for any future missed appointments or cancellation with no 24-hour notice.
2. Date