New Patient Intake Form

Patient Information

First Name:

Last Name:

Date of Birth:

Email Address:

Phone (Mobile):

Consent for appointment reminders I authorize Bensa Chiropractic and Wellness to send appointment reminders to the phone number provided

Yes

Address (Home):

City:

State

Zip Code:

Occupation:

Employer Name:

Employer Phone:

How did you hear about our clinic?

Emergency Contact

First Name:

Last Name:

Phone:

Relationship:

Phone Type:

Home Mobile Work Other

Insurance Information

Do you intend to submit for health insurance?

Yes No (Skip to Complaint Summary Section)

Policy Holder

First Name:

Last Name:

Date of Birth:

Phone (Mobile):

Employer Name (Policy Holder):

Social Security #:

Home Address:

City:

State:

Zip Code:

Relationship to Patient:

Insurance Company Name:

Insurance Plan (i.e. HMO, PPO, etc.):

Insurance provider phone: (located in the back of the card)

Member ID/#:

Group number:

Height

Weight

Sex

Any chances of being pregnant? (If does not apply leave blank)

Yes

Unsure

Complaint Summary:

Describe complaint(s):

Date of onset

How it begin (trauma, sports injury, repetitive motion, other)?

How you describe your pain?

Sharp

Stabbing

Dull

Achy

Stiff/Sore

Numbness

Tingling

Throbbing

Other

If other, please explain:

Frequency of complaint

Occasional

Intermittent

Frequent

Constant

Daily activities most affected by this complaint:

Previous treatment for this complaint:

Are you taking medications or supplements to decrease pain?

Yes No

If you answered ‘Yes’ , please explain (Prescriptions or OTC):

Have You Had Any Diagnostic Testing Performed for Above Complaint?

X-Ray(s)

CT Scan

MRI

Other

No Tests Have Been Performed

If other, please explain:

Health Summary

What type of exercise?

Smoking Preference:

How often(packs a day)?

How many drinks a weeks?

Supplements (frequency)

Current medications/ Frequency/ Dosage

Allergies

Hospitalizations

Family medical conditions

High blood pressure

Diabetes

Heart problems

Cancer

Osteoarthritis

Other (explain)

Unknown

None

Family member / Please Explain Below:

Previous accidents

Previous Injuries

Surgeries

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

This office is required to notify you in writing, that by law, we must maintain the privacy and confidentiality of your Personal Health Information. In addition, we must provide you with written notice concerning your rights to gain access to your health information, and the potential circumstances under which, by law, or as dictated by our office policy, we are permitted to disclose information about you to a third party without your authorization. Below is a brief summary of these circumstances.

Permitted Disclosures:

Treatment purposes - discussion with other health care providers involved in your care
Inadvertent disclosures - open treating area means open discussion. If you need to speak privately to the doctor, please let our staff know so we can place you in a private consultation room
For payment purposes - to obtain payment from your insurance company or any other collateral source
For worker’s compensation purposes - to process a claim or aid in investigation
Emergency - in the event of a medical emergency, we may notify a family member
For public health and safety - in order to prevent or lessen a serious or eminent threat to the health or safety of a person or general public
To governmental agencies or law enforcement - to identify or locate a suspect, fugitive, material witness, or missing person
For military, national security, prisoner, and government benefits purposes
Deceased persons - discussion with coroners and medical examiners in the event of a patient’s death
Telephone calls or emails and appointment reminders - we may call your home/cell and leave voice/text messages regarding an appointment, a missed appointment, or notify you of changes in practice hours or upcoming events
Announcing names in queue at the front desk & reception area - we announce the first and last names of patients in queue that are waiting to be treated (eg. Jane Smith, please proceed to room 2?). Please notify the office manager if you would like this to be changed
Change of ownership - in the event this practice is sold, the new owners would have access to your Personal Health Information

Your rights:

To receive an accounting of disclosures
To receive a paper copy of the comprehensive Detail Privacy Notice
To request mailings to an address different than residence
To request restrictions on certain uses and disclosures and with whom we release information to, although we are not required to comply. If, however, we agree, the restriction will be in place until written notice of your intent to remove the restriction.

Electronic Signature

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Informed Consent

Please read the document in its entirety prior to signing. It is important that you understand the information contained in this document. Please ask questions before you sign if there is anything that is unclear.

A patient, in coming to Bensa Chiropractic and Wellness, LLC, gives the doctors permission and authority to care for the patient in accordance with the chiropractic exam, analysis, diagnosis, and treatment of the joints and soft tissues.

As with any healthcare procedure, there are certain complications which may arise during the chiropractic adjustment and other clinical procedures. The chiropractic manipulation and other therapy are usually beneficial and seldom cause any problems. In rare cases, possible complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, cervical myelopathy, costovertebral strains and separations, and physical therapy burns. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications, including stroke. Some patients will feel some stiffness and soreness following the first few days of treatment. We will make every reasonable effort during the examination to screen for contraindications to care; however, it is the responsibility of the patient to make it known, or to learn through health care procedures whatever he or she is suffering from: latent pathological defects, illnesses or deformities which would otherwise not come to the attention of the doctors.

Fractures are rare occurrences and generally result from some underlying weakness of the bone which is screened for during the consultation, examination, and x-ray. The incidences of stroke are exceedingly rare and are estimated to occur between once in one million and once in ten million cervical adjustments.

Other treatment options for your condition may include:

• Self-administered, over the counter analgesics and rest

• Medical care and prescription drugs such as anti-inflammatory, muscle relaxants, and pain killers

• Hospitalization

• Surgery

Remaining untreated may allow the formation of adhesions and arthritis and reduce mobility which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed.

I have read or have had read to me the above informed consent and I understand that if I am accepted as a patient by the doctors at Bensa Chiropractic and Wellness, LLC, I am authorizing them to proceed with any treatment that may be necessary. Any questions I have had regarding these procedures have been answered to my satisfaction prior to my signing the consent form. I have made my decision voluntarily and freely.

Electronic Signature

Date

RIGHTS AND RESPONSIBILITIES

As our patient, you are hereby provided this Bill of Rights you have the right to be notified in writing of your rights and obligations before treatment has begun. The patient's family or guardian may exercise the patient's right when the patient has been judged incompetent. We fulfill our obligation to protect and promote the rights of our patients, including the following:

Patient’s Rights:

As the patient/caregiver, you have the RIGHT to:

Be treated with dignity and respect.
Confidentiality of patient records and information pertaining to a patient's care.
Be presented with information at admission in order to participate in and make decisions concerning your plan of care and treatment.
Be notified in advance of the type of care, frequency of care, and the clinical specialty providing care and be notified in advance of any changes in your plan of care and treatment.
Be provided equipment and service in a timely matter.
Receive an itemized explanation of charges.
Express grievance without fear of reprisal or discrimination.
Receive respect for the treatment of one's property.
Be informed of potential reimbursements for services under Medicare, Medicaid or other third-party insurers based on the patient's condition an insurance eligibility (to the best of the company's knowledge).
Be notified of potential financial responsibility for products or services not fully reimbursed by Medicare, Medicaid or other third-party insurers (to the best of the company's knowledge).
Be notified within 30 working days of any changes in charges for which you may be liable.
Be admitted for service only if the company can provide safe, professional care at the scope and level of intensity needed; if we are unable to provide services then we will provide alternative resources.
Purchase inexpensive or routinely purchased a durable medical equipment.
Expect that we will honor the manufacturer's warranty for equipment purchased from us.
Receive essential information in a language or method of communication that you understand.
Each patient has a right to have his or her cultural, psychological, spiritual, and personal values, beliefs and preference respected.
To be free from mental physical, sexual, and verbal abuse, neglect, and exploitation.
Access, request, and amendment to, and receive an accounting of disclosures regarding your health information as permitted under applicable law.

CUSTOMER RESPONSIBILITIES

As the patient/caregiver, you are RESPONSIBLE for:

Notifying the company of change of address, phone number, or insurance status.
Notify the company when service or equipment is no longer needed.
Notify the company in a timely matter if extra equipment or services will be needed.
Participating as in the plan of care/treatment.
Notifying the company of any change in condition, physical orders, or physician.
Notifying the company of an incident involving equipment.
Meeting the financial obligations of your health care as promptly as possible.
Providing accurate and complete information about president complaints, past illnesses, hospitalizations, medications, and other matters pertinent to your health.
Your actions if you do not follow the plan of care/treatment.

OTHER RIGHTS

As your provider of choice, we have the right to:

Terminate services to anyone who knowingly furnishes incorrect information to our company to secure durable medical equipment.
To refuse services to anyone who seeks direct care in threatening behavior, intoxicated by alcohol, drugs and/or other chemical substance and will potentially jeopardize the safety our staff and/or patients.

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Financial Policy

SCHEDULING:

While we do schedule appointments during regular hours (to reduce waiting time for you and others), patients are welcome to stop in at any time. Please be aware, however, that walk-in patients will be seen after all regularly schedule patients have been treated.
Although we do not charge for missed or cancel chiropractic appointments, we do request 24-hour notice. In consideration of our patients, we will be unable to schedule further appointments if three consecutive appointments are missed without notification or canceled without 24-hour notice.

PAYMENT:

Payment is expected in full at the time the services are rendered.
For your convenience we accept cash, checks, debit and credit cards.
Should care be discontinued for any reason other than discharge by the doctor, any outstanding balance will become immediately due and payable in full.

INSURANCE:

Our office verifies insurance coverage in an effort to determine chiropractic coverage under your current policy. As benefits quoted are not a guarantee of coverage of benefits, it is responsibility of the patient to contact their insurance if there is a discrepancy or error in benefits processing. Kindly keep in mind that you, as the patient, are responsible for any and all charges incurred in our office.
Please provide us with your most current insurance card and information. If your insurance changes during the year, please let us know so that we may bill using the most current insurance information.
Although we are not obligated to accept insurance payments on assignment from all carriers, we may do so as a courtesy to you, based on our experience with your insurance.
The patient/insured is responsible for any portion of the claim mot covered by insurance.
Please remember it that insurance coverage is a contract between you and your insurance company.
Please provide any secondary insurance information so we may file on your behalf.

REFUNDS:

If there is a credit due, the patient will have the option of using the credit towards future visits or calling the office and requesting a refund.

It is the goal of the office to provide you with the finest quality chiropractic care available. If you have any questions with regards to your health or any of our policies, please let us know. We welcome your referrals and look forward to a doctor – patient relationship that works for our mutual benefits.

I have read and agree to the guidelines of this financial/insurance policy.

I, the undersigned, have insurance coverage with the (Health Insurance Company listed below) and assign directly to Bensa Chiropractic and Wellness, LLC all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all changes whether paid by insurance. I hereby authorize Bensa Chiropractic and Wellness to release all information necessary to secure the payment of benefits. I authorize the use of the signature on all my insurance submission whether manual or electronic.

Health Insurance coverage

I, the undersigned, have insurance coverage with (Health Insurance) Insurance Company and assign directly to Bensa Chiropractic and Wellness, LLC all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all changes whether paid by insurance. I hereby authorize Bensa Chiropractic and Wellness to release all information necessary to secure the payment of benefits. I authorize the use of the signature on all my insurance submission whether manual or electronic.

Electronic Signature

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