Confidential Patient / Injury Information

Please correct the errors described below.

Patient Information

Claim Information

Insurance Information


A. I hereby authorize the release of any medical information necessary to process this claim and request payment of insurance benefits either to myself or to the party who accepts assignment. Additionally, I hereby authorize the release of any medical information to any third party as I deem necessary for my medical benefit

B. I authorize payment of any medical benefit from third parties for benefits submitted for my claim to be paid directly to this office. I authorize the direct payment to this office of any sum I now or hereafter owe to this office by my attorney, out of the proceeds of any settlement of my case and by any insurance company contractually obligated to make payment to me or you based upon the charges submitted for products and/or services rendered.

C. I understand and agree that health and accident policies are an arrangement between the insurance carrier and myself. Furthermore, I understand that this office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to this office will be credited to my account upon receipt.

D. However, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for products or professional services rendered will be immediately due and payable.

If Injury involved a vehicle (If not skip to head position)

Head Position

Confidential Patient/Injury Information

If you have experience any of the following conditions in the past please mark (P) on the box. If you are currently experiencing any of the following conditions please mark (C) on the box provided.


I certify that I have read and I understand the above information to the best of my knowledge. The questions above have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize this office to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such chiropractic care to third party payers and/or health practitioners. I authorize and re quest my insurance company to pay directly to this office benefits otherwise payable tome. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

Confidential Patient / Injury Information

Please check on the first (1st) box if you had any of these symptoms before collision.
Please check on the second (2nd) box if you had any of these symptoms after the collision.
Place a check on the third (3rd) box if you are experiencing any of these symptoms today.
Leave the last box blank (for office use only).

Thinking / Remembering



Emotion / Mood / Affect

Head, Face and Neck Pain

Back Pain

Upper Body Pain

Lower Body Pain

Thank you for taking the time to fill out this form as completely as possible. Successful health care and preventive medicine are only possible when the practitioner has a complete understanding of the patient's physical,mental and emotional state.

Authorization for the Release of Medical Records

(Also list maiden name and other names used)

I hereby request and authorize:

Live Health, PC | PO Box 2415 | Wilsonville, OR 97070
503-855-4465 Phone 971-249-8767 Fax

This authorization will be effective for six months after the date signed, unless cancelled in writing. I understand that the cancellation will have no effect on information released prior to receiving the cancellation. A copy of this authorization is a valid as the original.

If signing for a minor patient, I hereby state that my parental rights have not been revoked by a court of law.
Notice to recipient of information: This information has been disclosed to you from confidential records, which are protected by law. Unless you have further authorization, laws may prohibit you from making any further disclosures of this information without the specific written consent of the patient of legal representative.

Your information will be encrypted.