Personal Information: (Required)
Medical History: (Required)
What Tobacco products?
Do you drink alcohol? If so how often?
Which Problem(s) would you like us to evaluate today?
How did this happen?
When did this begin?
Have you had this before?
If so when?
Is it worse in the AM PM or worse throughout the day?
Is it getting Better Worse Unchanged
Who else have you seen for this problem?
What % of the day do you experience this?
(>25%) (25-50%) (50-75%) (75-100%)
What makes it better?
What makes it worse?
||Kind of Pain
Please indicate the location of the pain on the figures.
Authorizations and Releases
This policy outlines the way Patient Health Information (PHI) will be used in this office and the patient's rights concerning those records. You must read and consent to this policy before receiving services. For more information about Health Information Portability and Accountability Act (HIPAA) and health information privacy visit: hhs.gov - Understanding Health Information Privacy
The patient understands and agrees to allow this office to use their PHI for the purpose of treatment, payment, health care operations and coordination of care. The patient agrees to allow this office to submit requested PHI to the payor(s) named by the patient for the purpose of payment. This office will limit the release of all PHI to the minimum necessary to receive payment.
The patient has the right to examine and obtain a copy of their 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. This office is not obligated to agree to those restrictions.
The patient's written consent shall remain in effect for as long as the patient receives care at this office, regardless of the passage of time, unless the patient provides written notice to revoke their consent. A revocation of consent will not apply to any prior care or services.
This office is committed to protecting your PHI and meeting its HIPAA obligations: Staff have been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures.
Patients have the right to file a formal complaint with our privacy official about any suspected violations.
This office has the right to refuse treatment if the patient does not accept the terms of this policy.
***Consent to Professional Treatment***
I certify that all information provided to this practice is true and correct, to the best of my knowledge. I hereby give consent to this practice and its health care providers, consultants, assistants, or designees to render care and treatment to me as they deem necessary. I recognize that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made as to the result of evaluation and treatment. If the patient is a minor child, under the age of eighteen (18) at the date of treatment, I hereby stipulate that I am the legal guardian of the child, and grant my consent for the treatment of the child as provided for herein. I acknowledge that may refuse treatment at any time.
Consent to Perform and Interpret X-rays
I hereby consent to the performance of diagnostic x-rays as deemed necessary by the attending physician of this practice and acknowledge that certain risks are associated with x-rays. If applicable, I certify that I am a parent or legal guardian of the patient and I hereby authorize the performance of diagnostic x-rays on said minor as requested by the physician. At this time, I know of no condition which the taking of x-rays would further complicate.
I further agree that this practice may seek outside interpretation of my x-rays by a qualified professional not employed by this practice. I agree to any additional fees associated with this service and assigns benefits to be paid directly to that professional by my third-party payor.
Females: Regarding Possibility of Pregnancy
This is to certify that, to the best of my knowledge, I am NOT pregnant. The doctor and certified staff have permission to perform diagnostic x-rays. I am aware that taking x-rays, particularly those involving the pelvis, can be hazardous to a fetus.
Females: Consent to X-Ray During Pregnancy
This is to certify that, I am or may be pregnant and that the doctor or certified staff has my permission to perform diagnostic x-rays involving any cervical spine (neck) or extremities (arms or legs), on the condition that lead shielding be used over the trunk of my body. I have been advised that certain x-rays, particularly those involving the pelvis, can be hazardous to a fetus.
Assignment of Benefits and Release of Records
I hereby assign to this practice all of my medical and procedure benefits to which I am entitled, including major medical benefits. I hereby authorize and direct my insurance carrier(s), including Medicare and other government sponsored programs if applicable, private insurance and any other health plans to issue payment directly to this practice for medical services rendered. This assignment is irrevocable.
I hereby authorize this practice to release any medical or other information required by third party payers, including government agencies, insurance carriers, or any other entities necessary to determine insurance benefits or benefits payable for related services and supplies provided to me by the practice.
***Financial Obligation and Appointment Policy***
I hereby accept full financial responsibility for services rendered by this practice. I accept full responsibility for any fees incurred, regardless of insurance coverage. I understand that my insurance carrier may not approve or reimburse my medical services in full due to usual and customary rates, benefit exclusions, coverage limits, lack of authorization, or medical necessity. I further understand that I am responsible for fees not paid in full, co-payments, and policy deductibles and co-insurance except where my liability is limited by contract or State or Federal law. In some cases, exact insurance benefits cannot be determined until the insurance company receives the claim.
Should the account be referred to an attorney or collection agency for collection, I shall pay all fees, including but not limited to legal fees, collection agency fees, and any and all other expenses incurred in the collection of past due accounts. It is my responsibility to notify this practice of any changes in my health care coverage.You may direct any questions regarding this financial obligation to the clinic manager or physician.
Insurance / Medicare payment-Signature on File
I certify that the information given by me in applying for insurance and/or Medicare payment is true and correct.
I authorize this office and/or doctor to act as my agent in helping me obtain payment of my insurance and/ or Medicare benefits, and I authorize payment of these benefits to this clinic and/or doctor of record on my behalf for any services and materials furnished.
Terms of Acceptance
When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective.
At this clinic, our chiropractic adjustments have only one goal to achieve and maintain our patient's state of optimal physical well-being through the elimination of joint fixation. It is important that each patient understands the terminology we use, our objectives and the method that would be used to secure your ongoing help. At this clinic our chiropractic method of correction is by specific adjustments to the spine and peripheral joints.
An adjustment is a specific application of forces to facilitate the bodies' correction of subluxation. A subluxation is a fixation of one or more of the 24 vertebra in the spinal column, or fixations of the peripheral joints, which causes alteration of their function, resulting in a lessening of the bodies and inability to express its maximum health potential.
Therefore, this clinic adjustments are intended to correct fixation of the spine and peripheral joints. By providing chiropractic adjustments this clinic seeks to improve our patients’ state of optimal physical well-being, and not merely the absence of disease. This clinic’s program of achieving optimum health does not include the treatment of any disease or non-chiropractic condition through adjusting. If during the course of our chiropractic evaluation, we encounter disease or non-chiropractic related findings we will also inform you and advise that you seek a thorough diagnosis and treatment of those findings by a healthcare professional specializing in those areas. Our ONLY method of reducing fixation for purpose maintaining optimal joint function, is the targeted adjustment.
While the adjustment and modalities are delivered in this office, strictly for the purpose of reducing joint fixations/subluxations and maintaining health,* we do offer Spinal Decompression for the treatment of chronic low back pain and sciatica (sciatic leg pain/pinched nerve), caused by bulging discs, herniated discs or degenerative disc disease, and facet syndrome.
I, (Print Name) have read and fully understand the above statements.
All questions regarding the doctor’s objectives pertaining to my care in this office have been answered to my complete satisfaction.
Patient Privacy, Informed Consent and Non-Billing Statement
Requested Restrictions on certain Disclosures Of Health Information: In the case that an individual requests under paragraph (a)(1)(i)(A) of section 164.522 of title 45, Code of Federal Regulations, that a covered entity restrict the disclosure of the protected health information of the individual, notwithstanding paragraph (a)(1)(ii) of such section, the covered entity must comply with the requested restriction if:
Except as otherwise required by law, the disclosure is to a health plan for purposes of carrying out payment or health care operations and is not for purposes of carrying out healthcare services.
The protected health information pertains solely to a health care item or service for which the health care provider involved has been paid out-of-pocket in full.
I understand and am informed that some risks are associated with chiropractic adjustments, including, but not limited to, sprains, dislocations, fractures, disc injuries, strokes and paralysis.
I give permission to this clinic to use my address, phone number and clinical records to contact me with notifications, birthday cards, holiday related cards, information about treatment alternatives, or other health related information.
If this clinic contacts me by phone, I give them permission to leave a message on my answering machine or a voicemail.
I give this clinic permission to provide chiropractic services to me in an open room where other patients are also being attended to. I am aware that other persons in the office may overhear some of my protected health information during the course of care. Should I need to speak with the doctor at any time in private, the doctor will provide a room for the these conversations.
I give this clinic permission to access my patient care records in accordance with all applicable laws.
I (Patient Name) hereby direct this clinic shall not submit any billing data or related claim(s) for, or on, my behalf to any private insurance program, Medicare or any Secondary Medicare Insurance Program carrier with whom I have insurance coverage; exceptions are at the discretion of the doctor. I hereby acknowledge that I will be financially responsible to remit payment in full for all services provided to me at this clinic. By signing this form you understand the informed consent and are giving permission to use and disclose your protected health information in accordance with the directives listed.
(Patient Printed Name)