Accelerated Medical - New Patient Intake

Patient Data

*Email will not be shared and will only be used for occasional office announcements and appointment reminders

CMS requires providers to report both race and ethnicity

Medical History

Additional Reported History

Have you ever:

Reason for this Visit

Family History

Has anyone in your immediate family (mother, father, grandparents, brothers, sisters, children) had the following:

Conditions

Medications

List any medications and supplements you are taking, as well as the dosages and frequency below:

Please list any known medication, environmental, food or other allergies below:

Review of Symptoms

Please use the scale below (0 to 4) to rate each of the symptoms on this page according to your health status over the past 30 days:

0 = Never have this symptom
1 = Occasionally have this symptom, effect not severe
2 = Occasionally have this symptom, effect is severe
3 = Frequently have this symptom, effect not severe
4 = Frequently have this symptom, effect is severe

Head:

Energy / Activity:

Lungs:

Eyes:

Weight:

Heart:

Ears:

Emotions:

Digestive Tract:

Nose:

Mind:

Skin:

Mouth and Throat:

Joints / Muscles:

Previous Treatment

Women Only

Assignment of Health Plan Benefits and Rights, Designation of Personal Representative and an ERISA/PPACA Representative and Beneficiary

I understand and agree that (regardless of whatever health insurance or medical benefits I have), I am ultimately responsible to pay Accelerated Medical, PLLC as well as all employees, employers, representatives, and agents thereof, (hereinafter collectively referred to as “Healthcare Provider”) the balance due on my account for any professional services rendered and for any supplies, tests, or medications provided. I hereby authorize payment of, and assign my rights to, any health insurance or medical plan benefits directly to Healthcare Provider for any and all medical/healthcare services, supplies, tests, treatments, and/or medications that have been or will be rendered or provided; as well as designating and appointing Healthcare Provider as my beneficiary under all health insurance or medical plans which I may have benefits under. I hereby authorize the release of any health status, conditions, symptoms, or treatment information contained in your records that is needed to file and process insurance or medical plan claims, to pursue appeals on any denied or partially paid claims, for legal pursuit as to any unpaid or partially paid claims, or to pursue any other remedies necessary in connection with same. I hereby assign directly to Healthcare Provider all rights to payment, benefits, and all other legal rights under, or pursuant to, any health plan (including, but not limited to, any ERISA governed plan/insurance contract, PPACA governed plan/insurance contract) rights that I (or my child, spouse, or dependent) may have under my/our applicable health plan(s) or health insurance policy(ies). I also hereby appoint and designate that Healthcare Provider can act on my/our behalf, as my/our Personal Representative, ERISA Representative, and PPACA Representative as to any claim determination, to request any relevant claim or plan information from the applicable health plan or insurer, to file and pursue appeals and/or legal action (including in my name and on my behalf) to obtain and/or protect benefits and/or payments that are due (or have been previously paid) to either Healthcare Provider, myself, and/or my family members as a result of services rendered by Healthcare Provider, and to pursue any and all remedies to which I/we may be entitled, including the use of legal action against the health plan, the insurer, or any administrator. I hereby also declare that Healthcare Provider is my/our beneficiary regarding my/our health plan as contemplated by both ERISA and PPACA, and that Healthcare Provider can pursue any and all rights that I/we may have under state and/or federal law regarding my/our health plan. This assignment, appointment, and designation will remain in effect unless revoked by me in writing. It is my intent that the effective date of this document shall relate back to include all services, supplies, tests, treatments, or medications that have been previously provided by Healthcare Provider. A photocopy or scan of this document is to be considered as valid and as enforceable as the original.

I agree to pay all amounts that are not covered by my insurer(s) including applicable co-payments and/or deductibles for which I am responsible.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

HIPAA Consent for Purposes of Treatment, Payment & Healthcare Operations

In this document, “I” and “my” refer to the patient, and the “Clinic” refers to Accelerated Medical

I consent to the use or disclosure of my protected health information by the Clinic for the purpose of analyzing, diagnosing, or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations of the Clinic. I understand that analysis, diagnosis, or treatment of me by the Clinic may be conditioned upon my consent as evidenced by my signature below. I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment, or healthcare operations of the practice. The Clinic is not required to agree to the restrictions that I may request. However, if the Clinic agrees to a restriction that I request, the restriction is binding on the Clinic. I have the right to revoke this consent, in writing, at any time, except to the extent that Clinic has taken action in reliance on this Consent. My "protected health information" means health information, including my demographic information, collected from me and created or received by my physician, another health care provider, a health plan, my employer, or a health care clearinghouse. This protected health information relates to my past, present or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me. The Notice of Privacy Practices for Clinic is available at the front desk at 1810 Pinion Road, Elko, Nevada 89801. This Notice of Privacy Practices also describes my rights and duties of the Clinic with respect to my protected health information. The Clinic reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the Clinic and requesting a revised copy be sent in the mail or asking for one at the time of my next appointment.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Terms of Acceptance and Consent to Treat

Open Floor Environment
Accelerated Medical utilizes an “open treatment area” in which several people may be treated at the same time and in close proximity, and any exercises and therapies will be done in a group setting in this open environment. Complete privacy may not be possible in this setting, therefore if you would prefer to be seen in a private room or have a question or concern that you wish to be addressed in private, it is your responsibility to let us know and we will do our best to accommodate your wishes.

Children in the Office
Children are always welcome in the office; however their safety and wellbeing are not the responsibility of the doctors or staff. By bringing children into the office you understand and agree to the fact that they are solely your own responsibility and must be kept off the treatment floor and under complete control at all times.

I hereby authorize the physicians and staff to perform such services as deemed necessary by the physician to diagnose and treat my condition(s). Further, I authorize assignment of my insurance rights and benefits directly to this provider and also authorize the release of such information as is needed to process insurance claims. I understand that I am responsible for all charges which may include legal fees, collection fees, or other expenses incurred by the provider in collection my account. I hereby order all parties to accept a copy of this release and assignment in lieu of the original. This shall remain in effect until revoked by me in writing.

By my signature below I acknowledge that any questions regarding the doctor’s objectives pertaining to my care in this office have been answered to my complete satisfaction and I have a full understanding of the office policies and practices. I therefore accept care to be rendered at Accelerated Medical.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Pain Diagram

Please indicate by marking the location of your pain and discomfort on the diagram below. Use the letters noted below to describe each area of pain that has been circled.

D: Dull
B: Burning
N: Numb
S: Stabbing/cutting
T: Tingling (pins and needles)
C: Cramping/spasm

Pain Scale

Please use the scales below to mark your pain levels for EACH region you experience pain (see example). Please indicate your pain levels using the last 3 months as your reference. If you have completed this form before, indicate your average pain levels since the last time you completed this form.

Pain Disability Index

The rating scales below are designed to measure the degree to which several aspects of your life are presently disrupted by pain. Respond to each category by indicating the OVERALL impact of pain in your life, not just when the pain is at its worst.

For each of the six categories listed, please circle the number which best describes your typical level of activities.
A score of “0” means no disability at all, and a score of “10” signifies that all of the activities you would normally be involved with have been totally prevented by pain.

Informed Consent for Conservative Care

To the patient: You have a right to be informed about your condition, the recommended treatment, and the potentiality of any risks involved with the recommended treatment. This information will assist you in making an informed decision whether or not to have the treatment. This information is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give or refuse to give your consent to treatment.

If elected, the chiropractic adjustments will be performed by licensed Doctors of Chiropractic (DC) working at this office or serving as a locum or back up doctor.

In rare cases, there have been reported complications of vertebral artery dissection (stroke) when a patient receives a manual cervical adjustment. The complications reported can include temporary minor dizziness, nausea, paralysis, vision loss, locked in syndrome (complete paralysis of voluntary muscles in all parts of the body except for those that control eye movement), and death. I do not expect the doctor to be able to anticipate and explain all risks and complications. I understand that recent research suggests no evidence of excess risk of VBA stroke associated with chiropractic care compared to primary care physician visits. (University Health Network Research Ethics Board Approval number 05-0533-AE). *SEE BELOW FOR REFERENCE* I also understand that no guarantees or promises have been made to me concerning the results expected of treatment.

I wish to proceed with the prescribed care the Doctor and/or Medical Provider have deemed to be medically necessary in the care and treatment of my condition. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions. All of my questions have been answered to my satisfaction. By signing below, I consent to the treatment plan. I intend this consent form to cover the entire course of my treatment for my current condition.

To be completed by the Patient's representative

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

*Kosloff TM, Eltond, Tao J, Bannister WM. Chiropractic care and the risk of vertebrobasilar stroke: results of a case-control study in U.S. commercial and Medicare Advantage populations. Chiropractic Manipulation Therap. 2015 Jun 16;23:19. doi: 10.1186/s12988-015-0063-x. PMID:26085925; PMCID: PMC4470078.

Minor Consent

I hereby authorize and request Dr. Wade Taylor D.C. and/or Dr. Shannon McKinney D.C. and/or Dr. Lynda Flowers, DNP, APRN, FNP-C. to perform diagnostic tests and render chiropractic adjustments and other treatment to my child. This authorization also extends to all other providers and office staff members and is intended to include radiographic examination at the doctor’s discretion.

As of this date, I have the legal right to select and authorize health care services for the minor child named above.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

PATIENT CONSENT FOR THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

It is the policy of our practice that all physicians and staff preserve the integrity and confidentiality of protected health information (PHI) pertaining to our patients. The purpose of this document is to ensure that our practice and its physicians and staff have our patients’ consent to use necessary medical and PHI to provide the highest quality medical care possible while protecting the confidentiality of our patient's information.

PLEASE REVIEW THE FOLLOWING AGREEMENT:

I hereby give my consent for the above chiropractic practice to disclose protected health care information about me to carry out treatment, payment, and healthcare operations. The Privacy Practices Notice provides a more complete description of such uses and disclosure.

I have the right to review the Privacy Practices Notice prior to signing this consent. The chiropractic practice reserves the right to revise its Privacy Practice Notice at any time. A revised Privacy Notice may be obtained by forwarding a written request to the listed practice at 1810 Pinion Road, Elko, NV 89801.

With this consent, the practice may mail or e-mail to my home or other alternate locations and leave a voicemail or in-person in reference to any of the items that assist the practice in carrying out treatment, payment, and healthcare operations, such as appointment reminder cards and patient statements, as long as they are marked Personal and Confidential.

Also, I give consent for this practice to speak to the person named below regarding my healthcare and financial account. By signing this form, I am consenting to the above chiropractic practice’s use and disclosure of my protected health care information to carry out needed treatment, payment, and healthcare operations. I may revoke or limit my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, the practice may decline treatment to me.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Financial Policy

Cancellation and Missed Appointment and Massage Policy

Our goal is to provide quality individualized chiropractic care in a timely manner. "No-shows" and late cancellations inconvenience those individuals who need access to Dr. Taylor’s care in a timely manner. We would like to remind you of our office policy regarding missed appointments. This policy enables us to better utilize available appointments for our patients in need of chiropractic care.

No Show Policy

A "no-show" is someone who misses an appointment without canceling it in an adequate manner. This will also apply to late cancellations.

• First missed appointment: there will be no charge
• Second missed appointment: $25 fee will be billed to your account
• Third missed appointment: $50 fee will be billed to your account and you will need to meet with Dr. Taylor to see if you are a good fit for our practice.

Massage Policy

A fee equaling half of the price of the scheduled massage appointment for all missed massage appointments that fail to give 24-hour cancellation notice or if you are a no show for your appointment. Notice to all Personal Injury Patients: You will be charged accordingly as well. We will not charge your Personal Injury Insurance the fee. You will be responsible for the charge of the No Show/Missed Appointment.

Please understand that we will make every effort to make sure that you receive your text reminders or reminder calls. The text reminders are sent via the internet and we cannot guarantee that they will be sent out if there is an issue with the service of our internet provider.

HydroMassage Policy

HydroMassage is a fully customizable, user-friendly massage system that gives you a powerful, heated, deep-tissue massage in as little as 10 minutes.

You will stay fully clothed, dry, and comfortably supported while powerful waves of water are directed at specific areas of the body - giving you the deepest and most relaxing massage available.

HydroMassage offers all the benefits of traditional massage without the expense or time commitment. Now you can experience an incredible massage every day!

Rules and Restrictions for use of the HydroMassage:

1. Please remove any sharp objects such as belts, keys, phones, or knives
2. Please empty pockets
3. Please remove shoes4. The HydroMassage has a 350-pound weight limit

Accelerated Medical Patient’s Rights and Responsibilities

THE PATIENT HAS THE RIGHT TO:

1. Receive Services without regard to age race, color, sexual l orientation, religion, marital status, sex, national origin, or sponsor;
2. Be created with consideration, respect, and dignity including privacy in treatment;
3. Be informed of services available at the Office;
4. Be informed of the provisions for off-hours emergency coverage;
5. Be informed of the charges for services, eligibility for third-party reimbursements, and when applicable, the availability of free or reduced-cost care;
6. Receive an itemized copy of his/her account statement, upon request;
7. Obtain from his/her Health Care Provider, or the Health Care Practitioner’s delegate, complete and current information concerning his/her diagnosis, treatment, and prognosis in terms the patient can be reasonably expected to understand;
8. Receive from his/her physician information necessary to give informed consent prior to the start of any non – emergency procedure or treatment or both;
9. Refuse treatment to the extent permitted by law and to be fully informed of the medical consequences of his/her action;
10. Refuse to participate in the experimental research;
11. Voice grievances and recommend changes in policies and services to the Office’s staff the operator and the New York State Department of Health without fear of reprisal;
12. Express complaints about the care and services provided and to have the Office investigate such complaints. If the patient is not satisfied by the Office’s response; the patient may complain to the Washington State Department of Health by filling out and mailing the form found at http://www.doh.wa.gov/Portals/1/Documents/2600/655005.pdf
13. Privacy and confidentiality of all information and records pertaining to the patient’s treatment;
14. Approve or refuse the release or disclosure of the contents of his/her medical record to any Health Care Practitioner and/or Health Care Facility except as required as by law or third-party payment contract;
15. Access his/her medical record pursuant to the provisions of the law;
16. To execute an Advance Directive; and
17. To receive pain management services.

THE PATIENT HAS THE FOLLOWING RESPONSIBILITIES:

1. To provide the Office with accurate health and medical information;
2. To ask all questions you may have regarding the treatment provided by the Office;
3. To consent by free will to all procedures;
4. To tell us if you do not understand procedures or instructions;
5. To follow after-care instructions as recommended by the Office;
6. To contact his/her Physician with post-testing questions or concerns;
7. To provide all necessary information regarding third-party payment sources;
8. To observe all the Office’s Policies and Regulations;
9. To keep appointments as scheduled, or advise the Office if the appointment cannot be kept; and
10. To be considerate of the other Patients and Personnel and respect the property of others and the Office.

Patient Rights and Responsibilities

• Patients have the right to be treated with dignity and respect.
• Patients have the right to fair treatment, regardless of race, ethnicity, creed, religious belief, sexual orientation, gender, age, health status, or source of payment for care.
• Patients have the right to have their treatment and other patient information kept private. Only by law may records be released without patient permission.
• Patients have the right to access care easily and in a timely fashion.
• Patients have the right to a candid discussion about all their treatment choices, regardless of cost or coverage by their benefit plan.
• Patients have the right to share in developing their plan of care.
• Patients have the right to the delivery of services in a culturally competent manner.
• Patients have the right to information about the organization, its providers, services, and their role in the treatment process.
• Patients have the right to information about provider work history and training.
• Patients have the right to information about clinical guidelines used in providing and managing their care.
• Patients have a right to know about advocacy and community groups and prevention services.
• Patients have a right to freely file a complaint, grievance, or appeal, and to learn how to do so.
• Patients have the right to know about laws that relate to their rights and responsibilities.
• Patients have the right to know of their rights and responsibilities in the treatment process, and to make recommendations regarding the organization’s rights and responsibilities policy. I have read and understood my rights and responsibilities.
• Patients have the responsibility to treat those giving them care with dignity and respect.
• Patients have the responsibility to give providers the information they need, in order to provide the best possible care.
• Patients have the responsibility to ask their providers questions about their care.
• Patients have the responsibility to help develop and follow the agreed-upon treatment plans for their care, including the agreed-upon medication plan.
• Patients have the responsibility to let their provider know when the treatment plan no longer works for them.
• Patients have the responsibility to tell their provider about medication changes, including medications given to them by others.
• Patients have the responsibility to keep their appointments. Patients should call their providers as soon as possible if they need to cancel visits.
• Patients have the responsibility to let their provider know about their insurance coverage and any changes to it.
• Patients have the responsibility to let their provider know about problems with paying fees.
• Patients have the responsibility not to take actions that could harm others.
• Patients have the responsibility to report fraud and abuse.
• Patients have the responsibility to openly report concerns about the quality of care.
• Patients have the responsibility to let their provider know about any changes to their contact information (name, address, phone, etc).
• Patients have the right and the responsibility to understand and help develop plans and goals to improve their health.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.