NEW PATIENT PERSONAL INFORMATION FORM

Please correct the errors described below.

Upon the completion of your first visit, you will receive a Chiropractic Report to discuss the different types of Active Life Plans that are available to you. Chiropractic Active Life Plans are designed to help get you feeling better quickly and to help you and your family be as healthy as possible. Please review the explanations of the Chiropractic Active Life Plans prior to your Chiropractic Report appointment so you can choose the level of participation that supports you in reaching all of your health goals

As a result of my chiropractic care, I would like to:

Feel better quickly

Have a healthier body by keeping my nerve system healthy

Have a healthier spine

Live a healthier lifestyle

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

Medications

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Allergies

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Vaccinations:

Consent to Use PHI

Acknowledgement for Consent to Use and Disclosure of Protected Health Information Use and Disclosure of your Protected Health Information

Your Protected Health Information will be used by Back to Health Chiropractic Center, LLC or may be disclosed to others for the purposes of treatment, obtaining payment, or supporting the day-to-day health care operations of this office.

Please list those whom we may give your information to:

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Notice of Privacy Practices

You should review the Notice of Privacy Practices for a more complete description of how your Protected Health Information may be used or disclosed. It describes your rights as they concern the limited use of health information, including your demographic information, collected from you and created or received by this office.

I have received a copy of the Notice of Patient Privacy Policy.

Requesting a Restriction on the Use or Disclosure of Your Information

You may request a restriction on the use or disclosure of your Protected Health Information. This office may or may not agree to restrict the use or disclosure of your Protected Health Information. If we agree to your request, the restriction will be binding with this office. Use or disclosure of protected information in violation of an agreed upon restriction will be a violation of the federal privacy standards.

Notice of Treatment in Open or Common Areas

Note that some of your treatment may be performed in an "open area". Private areas are available upon request to discuss your health information upon request.

Revocation of Consent

You may revoke this consent to the use and disclosure of your Protected Health Information. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected.

By my signature below I give my permission to use and disclose my health information.

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

CONSENT TO CHIROPRACTIC EXAMINATION AND CARE

I hereby authorize Back to Health Chiropractic Center, LLC and its licensed doctors and assistants, based on my complaints and the history I have provided, to undertake an examination and provide an evaluation and treatment plan which may include chiropractic adjustments and other tests and procedures considered therapeutically appropriate. I also with to rely on the practice doctors to make those decisions about my care, based on the facts then known, that they believe are in my best interest.

The nature and purpose of the chiropractic examination and evaluation, the chiropractic adjustments and the other procedures that may be recommended during the course of my care have been explained and described to my satisfaction.

By signing below i acknowledge my consent to be examined:

The specifics of the doctor's recommendation will be further explained during a Report of Findings following your examination and any subsequent examinations and significant changes in your diagnosis or treatment plan.

Based on current findings, practice doctors have discussed my diagnosis and treatment plan, the benefits and expected improvement with the proposed treatment and the reasonable alternatives to the proposed treatment. They have also explained the cost of my proposed care (or provided me with a current fee schedule) and to the extent practicable the costs of reasonable alternatives to the proposed treatment.

To aid the understanding of my condition and the reasons for the proposed course of care, the practice has provided me with the specific pamphlets and other literature and practice doctors have answered my questions regarding the planned treatments and course of care that I will receive. Practice doctors have also explained that my diagnosis and treatments may change during the course of care and that they will advise me of material changes in my diagnosis and treatment options and answer any additional questions that I may have at any time.

I have also been advised that although the incidence of complications associated with chiropractic services is very low, anyone undergoing adjusting or manipulative procedures should know of rare possible hazards and complications which may be encountered or result during the course of care. These include, but are not limited to, fractures, disk injuries, strokes, dislocations, sprains, and those which relate to physical aberrations unknown or reasonably undetectable by the doctor.

I understand and accept that:

  1. I have the right to withdraw from or discontinue treatment at any time and that the Practice doctors will advise me of any material risks in this regard.
  2. That neither the practice of chiropractic nor medicine is an exact science and that my care may involve the making of judgments based upon the facts known to the doctor during the course of my care.
  3. That it is not reasonable to expect the doctor to be able to anticipate or explain all risks and complications or an undesirable result does not necessarily indicate an error in judgment or treatment.
  4. The Practice does not guarantee as to results with respect any course of care or treatment.
  5. My care and treatment will not be observed or recorded for any non-therapeutic purpose without my consent.

I have read this Consent (or have had it read to me) and have also had an opportunity to ask questions about the Consent and understand to my satisfaction the care and treatment I may receive. My signature below acknowledges my consent to the examination, evaluation and purposed course of care and treatments by the Practice.

Doctor's Notes:

Patient counseled by:

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

Consent to X-Ray

I hereby authorize Dr. (Please input Name below) and whomever he/she designates as his/her assistants to take x-rays of myself (or said minor).

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

Witness

Patient

Pregnancy Warning

  • I understand that if I am pregnant and have x-rays taken which expose my lower torso to radiation, it is possible to injure the fetus.
  • I have been advised that the 10 days following the onset of a menstrual period are generally considered to be safe for x-ray examination.

with thise factors in mind, I am advising my doctor that:

With full understanding of the above, and believing that I am not currently at risk, I wish to have an x-ray examination performed now.

I hereby authorize the Doctor to examine and treat any condition as he/she deems appropriate through the use of Chiropractic Health Care, and I give authority for these procedures to be performed. It is understood and agreed the amount paid the Doctor for x-rays is for examination only and the x-rays negatives will remain the property of this office.

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

ASSIGNMENT OF BENEFITS/ERISA AUTHORIZED REPRESENTATIVE FORM

Back to Health Chiropractic Center LLC

Financial Responsibility

I have requested professional services from Back to Health Chiropractic Center LLC Dr. Melani Crocker D.C. on behalf of myself and/or my dependents, and understand that by making this request, I am responsible for all charges incurred during the course of said services. I understand that all fees for said services are due and payable on the date services are rendered and agree to pay all such charges incurred in full immediately upon presentation of the appropriate statement unless other arrangements have been made in advice.

Assignment of Insurance Benefits

I hereby assign all applicable health insurance benefits to which I and/or my dependents are entitled to the said Dr. Melani Crocker D.C. I certify that the health insurance information that I provided to Dr. Melani Crocker D.C. is accurate as of the date set forth below and that I am responsible for keeping it updated.

I hereby authorize Dr. Melani Crocker D.C. to submit claims, on my and/or my dependent's behalf, to the benefit plan (or its administrator) listed on the current insurance card I provided to Dr. Melani Crocker D.C., in good faith. I also hereby instruct my benefit plan (or its administrator) to pay Dr. Melani Crocker D.C. directly for services rendered to me or my dependents. To the extent that my current policy prohibits direct payment to Dr. Melani Crocker D.C., I hereby instruct and direct my benefit plan (or its administrator) to provide documentation stating such non-assignment to myself and Dr. Melani Crocker D.C. upon request. Upon proof of such non-assignment, I instruct my benefit plan (or its administrator) to make out the check to me and mail it directly to Dr. Melani Crocker D.C.

I am fully aware that having health insurance does not absolve me of my responsibility to ensure that my bills for professional services from Dr. Melani Crocker D.C. are paid in full. I also understand that I am responsible for all amounts not covered by my health insurance, including co-payments, co-insurance, and deductibles.

Authorization to Release Information

I hereby authorize Dr. Melani Crocker D.C. to: (1) release any information necessary to my health benefit plan (or its administrator) regarding my illness and treatment: (2) process insurance claims generated in the course of examination or treatment; and (3) allow a photocopy of my signature to be used to process insurance claims. This order will remain in effect until revoked by me in writing.

ERISA Authorization

I hereby designate, authorize, and convey to Dr. Melani Crocker D.C. to the full extent permissible under law and under any applicable insurance policy and/or employee health care benefit plain: (1) the right and ability to act as my Authorized Representative in connection with any claim, right or cause in action that I may have under such insurance policy and/or benefit plain; and (2) the right and ability to act as my Authorized Representative to pursue such claim, right or cause of action in connection with said insurance policy and/or benefit plain (including but not limited to, the right and ability to act as my Authorized Representative with respect to a benefit plan governed by the provisions of ERISA as provided in 29C.F.R. $2560.5031(b)(4) with respect to any healthcare expense incurred as a result of the services I receive from Dr. Melani Crocker D.C. and, to the extent permissible under the law, to claim on my behalf, such benefits, claims, or reimbursement, and any other applicable remedy, including fines.

A photocopy of this Assignment/Authorization shall be as effective and valid as the original.

I hereby assign and authorize payment made directly to Back to Health Chiropractic Center LLC of the covered insurance benefits including major medical benefits, whether payable to me by Medicare, commercial insurance companies and/or managed care plans. I understand that my health insurance provider may not cover part or all of the medical services rendered.

I fully understand that I am financially responsible for and agree to pay all charges not paid by my health care coverage, including deductibles, co-insurance, and payments from insurance companies sent to me directly. In consideration of the chiropractic services furnished to me, I hereby agree to pay Back to Health Chiropractic Center LLC any balance due within ninety days from presentation of my bill. In the event of default I promise to pay legal interest on Indebtedness together with 35% collection costs and attorney fees as may be required to effect collections.

I have disclosed the names of all my health insurance providers' including tie-in-coverage and I represent that such health care coverage is in full force and effect at this time.

If prior authorization or certification for chiropractic services is required under my health care coverage, I agree to obtain both and furnish such authorization for certification.

I authorize the release of medical information as may be required to process the claims for payment of the chiropractic services rendered and it is expressly understood that the right of such information to be privileged is hereby waived. I understand that I have an opportunity to discuss with the Doctor and staff to my satisfaction the nature of the services to be provided.

I acknowledge that no guarantees have been made to me as to the results.

This assignment shall apply to all chiropractic services now rendered and to be rendered in the future until it is revoked. I agree to promptly notify your office of any change of address or change of insurance. A copy of this assignment shall be considered as valid as the original.

I voluntarily consent to the participation ef care, including treatment.

I certify that the information given by me in applying for payment under Title XVIlI and Title XI of the Social Security Act, is correct. I authorize release of any medical records concerning me to the Social Security Administration or its intermediary carriers, any information needed for this or related Medicare or Medicaid claim. I request payment of authorized benefits be made on my behalf. I assign the benefits payable for physician(s) services. I understand that I am responsible for my health insurance deductibles and coinsurance. As a courtesy for you, we may call you on the telephone when an appointment is missed and/or you have not been in for a while. If you do not wish for us to call you or mail you reminder cards please let us know in writing for you file.

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

Motor Vehicle Accident Information

General Information

Location

(Select one)

Passenger

Work from Left to Right and Select One


Patients Vehicle

Enter impact Information for up to three Vehicles or Objects

Impact Information: Vehicle or Object (I)

Impact Information: Vehicle or Object (II)

Impact Information: Vehicle or Object (III)

During Impact Information:

Body Impact (Indicate any parts of your body that were struck during the impact)

After Accident Information:

Pain (Indicate if you experienced any pain immediately following the accident)

Medical Information (Did you get medical care for this accident before coming to our office)

Previous Injuries

Later Symptoms (Please note any symptoms that started after the accident occurred)

hrs. per night
lbs.
lbs.

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

Patient Basic Information

1. Description of Accident/Injury/Onset

2. Your condition during and immediately after injury/onset

AUTO ACCIDENT INSURANCE INFORMATION

MED PAY (YOUR CAR INSURANCE)

MOST CAR INSURANCE POLICY'S HAVE A MEDICAL PAY THAT YOU ARE ENTITLED TO FILE CLAIMS ON FOR AND AUTO ACCIDENT YOU ARE INVOLVED IN. MISS OUR IS A NO FAULT STATE. FILING WITH YOUR MED PAY WILL NOT CAUSE YOUR CAR INSURANCE RATES TO INCREASE. IT IS NOT LEGAL TO DO SO.

I (Please input Name below) MED PAY (YOUR CAR INSURANCE) MOST CAR INSURANCE POLICY'S HAVE A MEDICAL PAY THAT YOU ARE ENTITLED TO FILE CLAIMS ON FOR AND AUTO ACCIDENT YOU ARE INVOLVED IN. MISS OUR IS A NO FAULT STATE. FILING WITH YOUR MED PAY WILL NOT CAUSE YOUR CAR INSURANCE RATES TO INCREASE. IT IS NOT LEGAL TO DO SO.

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

INSURANCE OF PERSON WHO HIT YOU

YOUR ATTORNEY'S NAME AND PHONE #

HEADACHE DISABILITY INDEX


SCORES

(100)
(52)
(48)

INSTRUCTIONS: Please CIRCLE the correction response:

INSTRUCTIONS: PLEASE READ CAREFULLY: The purpose of the scale is to identify difficulties that you may be experiencing because of your headache. Please check off "YES", "SOMETIMES", Or "NO" to each item. Answer each item as it pertains to your headache only.

Neck Disability Index

This questionnaire has been designed to give the doctor information as to how your neck pain has affected your ability to manage in everyday life. Please answer every section and mark in each section only ONE box which applies to you. We realize you may consider that two of the statements in any one section relate to you, but please just mark the box which MOST CLOSELY describes your problem.

Please read instruction: when your back hurts, you may find it difficult to do some of the things you normally do. Mark only the sentences that describe you today.

Oswestry Low Back Questionnaire

This questionnaire has been designed to give the doctor information as to how your back pain has affected your ability to manage in everyday life. Please answer every section and mark in each section only ONE box which applies to you. We realize you may consider that two of the statements in any one section relate to you, but please just mark the box which MOST CLOSELY describes your problem.

Your information will be encrypted.

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