Effective Date: November 1, 2026

1. Purpose of This Agreement

This agreement establishes the general policies, expectations, and responsibilities of patients receiving services at Trillium Sports Medicine.

These policies apply to new and existing patients receiving services at the practice.

2. Appointments, Cancellations & Scheduling

  • Patients are expected to arrive on time for scheduled appointments.
  • Patients should notify the office as soon as possible if they need to cancel or reschedule.
  • Repeated missed appointments or late cancellations may result in applicable fees or scheduling restrictions, provided the policy and fees have been disclosed in advance.
  • Appointment reminders may be provided by telephone, text message, or email.
  • Patients are responsible for keeping their contact information current.

3. Financial Responsibility & Payments

Patients acknowledge and agree to the following:

  • Patients are responsible for understanding their insurance coverage, including deductibles, copayments, coinsurance, exclusions, and limitations.
  • Insurance verification and benefit estimates do not guarantee that an insurance company will pay for services.
  • Patients may be responsible for charges not covered by insurance, subject to applicable law, insurance contracts, and separate financial agreements.
  • Any applicable copayments, deductibles, or other patient-responsibility amounts are due according to the office’s disclosed payment policies.
  • Patients are responsible for addressing outstanding balances and billing questions with the office.
  • The office may provide billing statements and payment reminders when appropriate.

4. Insurance Information & Claim Submission

  • Patients agree to provide accurate and current insurance information.
  • Patients must notify the office of any changes to their insurance coverage.
  • Trillium Sports Medicine may submit claims to insurance companies on behalf of patients when applicable.
  • Patients understand that the final determination of coverage and payment is made by the insurance company.
  • If a claim is denied, reduced, or not covered, financial responsibility will be determined according to applicable law, insurance agreements, and any applicable patient financial agreements.
  • Patients agree to cooperate with reasonable requests for information needed to process claims.

5. Personal Injury & Automobile Accident Cases

Patients receiving treatment related to an automobile accident or personal injury acknowledge the following:

  • Patients must provide accurate information regarding the accident, applicable insurance coverage, and any attorney representing them.
  • Patients should notify the office if their legal representation or insurance information changes.
  • The office may communicate with applicable insurance companies and other authorized parties regarding treatment and billing.
  • Patients may be asked to provide a separate written financial agreement, lien, letter of protection, or other applicable documentation.
  • Any agreement involving payment from an insurance settlement or other third-party source must be documented separately.
  • This agreement does not automatically create a lien, assignment of settlement proceeds, or authorization to release medical records to an attorney.
  • Financial responsibility will be determined by the applicable written agreements and governing law.

6. Patient Responsibilities & Medical History

Patients agree to:

  • Provide accurate personal information and medical history.
  • Disclose relevant health conditions, medications, allergies, previous injuries, and changes in their health.
  • Inform the doctor of new symptoms or concerns.
  • Ask questions if they do not understand a recommended treatment or procedure.
  • Notify the doctor if they experience unexpected symptoms or adverse reactions during treatment.
  • Follow agreed-upon treatment instructions and recommendations.

Patients understand that providing incomplete or inaccurate medical information may affect their care.

7. Treatment, Informed Consent & Results

  • Treatment recommendations are based on the doctor’s professional judgment and the patient’s individual circumstances.
  • Patients have the right to ask questions about recommended treatments, potential risks, benefits, and alternatives.
  • Separate informed consent may be required for specific treatments or procedures.
  • Patients may decline or discontinue treatment, subject to appropriate discussion of potential consequences.
  • Individual treatment results vary.
  • No specific outcome, recovery period, or result is guaranteed.

8. Collection, Use & Disclosure of Patient Information

Trillium Sports Medicine collects and maintains patient information to operate the practice and provide appropriate healthcare services.

Information collected may include:

  • Name, date of birth, address, telephone number, and email address.
  • Medical history, symptoms, diagnoses, and treatment records.
  • Insurance information, billing details, and payment history.
  • Accident information and attorney details when applicable.
  • Other information necessary for providing and coordinating healthcare.

How We Use Patient Information

Patient information may be used for the following purposes:

  1. Treatment: Providing chiropractic care, coordinating services, and communicating with other healthcare providers involved in treatment.
  2. Payment: Verifying insurance benefits, submitting claims, processing payments, and addressing billing matters.
  3. Healthcare Operations: Maintaining medical records, managing appointments, conducting quality improvement activities, and operating the practice.
  4. Communication: Contacting patients regarding appointments, treatment, billing, and other practice-related matters.
  5. Legal Compliance: Meeting applicable federal and California legal, regulatory, and reporting requirements.

When Patient Information May Be Shared

Patient information may be disclosed when permitted or required by applicable law, including:

  • Insurance companies and health plans for payment and claims processing.
  • Healthcare providers involved in a patient’s treatment.
  • Billing companies and other authorized business associates assisting the practice.
  • Attorneys, insurance representatives, or other third parties when the patient has provided appropriate authorization or another legal basis for disclosure exists.
  • Government agencies and regulatory authorities when required by law.
  • Other individuals or organizations when disclosure is otherwise permitted by applicable privacy laws.

Patient information will not be disclosed simply because an attorney, insurance representative, family member, or other third party requests it.

Protection of Patient Information

Trillium Sports Medicine takes reasonable administrative, technical, and physical measures to protect patient information from unauthorized access, use, or disclosure.

Patient information is handled in accordance with applicable federal and California privacy requirements, including HIPAA and the California Confidentiality of Medical Information Act.

9. Medical Records & Patient Privacy Rights

Patients have rights regarding their medical information, subject to applicable laws and exceptions.

These rights may include:

  • Requesting access to medical records.
  • Requesting copies of medical records.
  • Requesting corrections or submitting an addendum regarding information believed to be incomplete or inaccurate.
  • Requesting certain restrictions on the use or disclosure of protected health information.
  • Requesting confidential communications in certain circumstances.
  • Filing a complaint if they believe their privacy rights have been violated.

Requests involving medical records must follow the office’s established procedures and applicable legal requirements.

10. Telephone, Text Message & Email Communications

Trillium Sports Medicine may communicate with patients through telephone calls, voicemail, text messages, and email for practice-related purposes.

These communications may include:

  • Appointment confirmations and reminders.
  • Scheduling changes and follow-up communications.
  • Billing statements and payment reminders.
  • General office announcements.
  • Other communications related to the patient’s care.

Patients should notify the office if they have communication preferences or restrictions.

Patients should avoid sending sensitive medical information through unsecured communication methods.

11. Office Conduct & Patient Relationships

Trillium Sports Medicine strives to maintain a professional, respectful, and welcoming environment.

Patients are expected to:

  • Treat doctors, employees, and other patients respectfully.
  • Refrain from threatening, abusive, or disruptive behavior.
  • Follow reasonable office procedures.
  • Communicate concerns or complaints professionally.

The practice reserves the right to address inappropriate behavior and, when necessary, discontinue the patient-provider relationship in accordance with applicable law, professional obligations, and appropriate continuity-of-care procedures.

12. Policy Updates

Trillium Sports Medicine may update its office policies when necessary to reflect changes in practice operations, applicable laws, or regulatory requirements.

Material changes will be communicated when appropriate.

Changes to privacy practices will be addressed through the separate Notice of Privacy Practices as required by law.