New Patient Form

HEALTH INFORMATION

General Information

If yes, please indicate the following:

If yes, please indicate the following:

Please circle each current or past symptom listed.

I hereby authorize the doctor to examine and treat my condition as he/she deems appropriate through the use of chiropractic health care, and I give authority for these procedues to be performed. It is understood and agreed the imaging is for examination only and the negatives will remain the property of this office, being on file where they may be reviewed.

FAMILY HEALTH HISTORY

Please review the below listed diseases and conditions and indicate those that are current health problems of a family member by selecting C below. The designation P should be used to indicate a past health problem. Leave blank those spaces that do not apply. If you require more space, use the reverse side of this form.

Please complete the following three(3) questions regarding how you feel today.

Based on the picture below, input where you have pain or other symptoms.

2. Are you getting better?

3. Is there anything new?

I certify that the above information is complete and accurate to the best of my knowledge. I agree to notify this doctor immediately whenever I have changes in my health condition or health plan coverage in the future.

CONFIDENTIAL PATIENT INFORMATION

PATIENT INFORMATION:

CLAIM INFORMATION

AUTHORIZATIONS:

A. I hereby authorize 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.

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- this office by my attorney, out of proceeds of any settlement of my case and by any insurance company contractually obligated to make payment to me or you basecupon the charges submitted for products and services rendered.

C. I understand and agree that health and accident policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that this office will prepare any necessary reports and forms to assist me in maxing 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. 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 or products or professional services rendered will be immediately due and payable.

Patient Health Information Consent Form

We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we will begin any health care operations we must require you to read and sign this consent form stating that you understand and agree with how your records will be used. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent.

1. The patient understands and agrees to allow this chiropractic office to use their Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operations, and coordination of care. As an example, the patient agrees to allow this chiropractic office to submit requested PHl to the Health Insurance Company (or companies) provided to us by the patient for the purpose of payment. Be assured that this office will limit the release of all PHI to the minimum needed for what the insurance companies require for payment.
2. The patient has the right to examine and obtain a copy of his or her own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI. Our office is not obligated to agree to those restrictions.
3. A patient's written consent need only be obtained one time for all subsequent care given the patient in this office.
4. The patient may provide a written request to revoke consent at any time during care.This would not effect the use of those records for the care given prior to the written request to revoke consent but would apply to any care given after the request has been presented
5. For your security and right to privacy, all staff has been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures in our office. We have taken all precautions that are known by this office to assure that your records are not readily available to those who do not need them.
6. Patients have the right to file a formal complaint with our privacy official about any possible violations of these policies and procedures.
7. If the patient refuses to sign this consent for the purpose of treatment, payment and health care operations, the chiropractic physician has the right to refuse to give care.

I have read and understand how my Patient Health Information will be used and I agree to these policies and procedures.

IRREVOCABLE ASSIGNMENT OF BENEFITS

I understand that payment for services is due at the time they are rendered, but as a courtesy to me, Priority Health Chiropractic is willing to accept assignment of my benefits. I also understand that this courtesy may be withdrawn, at which time I would be totally responsible for the balance in full and any collection costs incurred.

RELEASE OF INFORMATION

1. You are authorized to release and information you deem appropriate concerning my physical condition to any insurance company, attorney, or adjustor in order to process any claim for reimbursement of charges incurred by me at your treatment facility.

RIGHT TO RECEIVE PAYMENT

2. I authorize and assign to you, the medical provider, the right to receive direct payment from my attorney or any insurance company, who may be obligated to pay me any sums. I further authorize the endorsement of my name to any draft or check containing my name to which you are legally entitled.

ASSIGNMENT OF RIGHT TO SUE

3. In the event any insurance company or attorney, obligated by contractual agreement to issue payments to me for your service charges, refuses to pay upon demand by you, I hereby assign and transfer to you the cause of action that exists in my favor against any such company or attorney and authorize you to prosecute said action either in my name or your name as you otherwise resolve said claim as you see fit. I understand that whatever amounts you do not collect from said insurance proceeds (whether it be all or part of what is due) shall be paid by me.

RIGHT OF LIEN

4. I also assign to you, the medical provider, and grant the right of lien against any and all claims against any third party whose negligence may have caused my injury, including their insurance, up to the amount of the bill for treatment.

STATUTE OF LIMITATIONS

5. I waive the Statute of Limitations regarding my doctor's right to recover from me directly.

ATTORNEY ASSISTANCE

6. I hereby direct my attorney to cooperate, assist and not interfere with you, the medical provider, in recovery of any Medpay benefits to which I may be entitled.

PATIENT: Please discuss any question or concerns with the Doctor before signing.

I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic x-rays, on me (or on the patient listed below, for whom I am legally responsible) by the doctors and staff of Priority Health Chiropractic.

I understand that chiropractic treatment is a procedure that involves movement of joints and soft tissue and that physical and exercise may also be prescribed.

I have had the opportunity to discuss with the doctor and/ or other clinic personnel the purpose and benefit of the chiropractic treatment and other treatments listed below. Alternatives to chiropractic care, which include rest, exercise, physical therapy, over the counter medications, medical treatment (drug therapy/surgery), as well as non-treatment, have been reviewed. The disadvantages to these approaches have been explained to me.

Although chiropractic adjustments are considered to be one of the safest, most effective forms of therapy for musculoskeletal problems, l understand and am informed that there are some risks to treatments. Risks include, but are not limited to, additional soreness, dizziness, fractures, nerve tissue damage, disc injuries, strokes, dislocations, sprains/strains, and skin irritation/burn. The probability of serious complications has been estimated at less than one in a million.

The risks associated with remaining untreated have been explained to me. These may include, but are not limited to, decreased mobility, increased pain/symptoms, scar tissue/adhesion formation, ossible nerve damage, increased inflammation and degenerative changes. It is possible that delaying treaiment will complicate future care.

In the interest of better serving our patients, we send all of x-rays to a licensed radiologist for review. We have negotiated a special rate of $40 for this service, which is a significant savings over standard fees. Because this service is not covered by insurance, this fee will be added to your account.

If you are unable to make an appointment please call us before your appointment to reschedule it so that it can be rescheduled at a later time. Failure to do so will result in a $25.00 no show fee.

I understand that chiropractic is not an exact science and that, therefore, reputable practitioners cannot fully guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the chiropractic treatment that I have requested and authorized. I have had the opportunity to read this form and ask questions. My questions have been answered to my satisfaction. I consent to the proposed treatment.

I understand that my treatment will consist of Chiropractic adjustments and/or physical therapy.