Electronic Health Records Intake Form

in compliance with requirements for the government HER incentive program

CMS requires providers to report both race and ethnicity.

Office Use Only:

OFFICE POLICY

INTIAL VISIT: A complete chiropractic examination will be performed prior to any treatment. X-rays may be necessary in order to rule out possible bone and joint diseases and to locate spinal misalignments. If you have recently had X-rays of your current problem, please inform us as they may aid in our diagnosis and thus eliminate the need for additional X-rays at this time.

INSURANCE COVERAGE: It is our policy to bill your insurance carrier as a courtesy to you. However, your bill is always your responsibility because insurance is an agreement between you and your insurance carrier.

MAJOR MEDICAL: You are expected to pay in full for services rendered today. You acknowledge you are responsible for all insurance co-pays and deductible amounts owed by you.

WORKERS COMPENSATION: Written consent/authorization must be provided to our office from your workers compensation adjuster in order to receive treatment in our office.

AUTO ACCIDENTS: I herby instruct and direct my auto insurance company to pay by check or
draft directly to the above listed provider. Auto insurance pays 80-100% for your care in order to qualify for this care you need to provide us with your claim number, and we will file medical claims on your behalf.

MEDICARE: Medicare allows an unlimited amount of chiropractic visits per year. You are responsible for your calendar year deductible. X-rays are required at a cost of $50.00, but not paid for by Medicare.

CASH PATIENTS: If you don’t have insurance all fees are payable when services are rendered unless prior arrangements have been made.

CANCELLED APPOINTMENTS: Chiropractic appointments require a 24 hour advance notice and Massage appointments require a 48 hour advance notice to avoid a $25.00 cancelation fee. This fee will be placed on your account and is 100% your responsibility.

MISSED APPOINTMENTS: Chiropractic appointments must be rescheduled within 24 hours of missed appointment, otherwise a $25.00 missed appointment fee will be required. Massage appointments will require a $25.00 missed appointment fee. These missed appointment fees will be placed on your account and is 100% your responsibility.

HIPAA
PRIVACY PRACTICES ACKNOWLEDGEMENT

I have read the Notice of Privacy Practices.

INFORMED CONSENT

It is important to acknowledge the difference between health care and the specialty of Chiropractic care. Chiropractic health care seeks to restore health through natural means without the use of medicine or surgery. This gives the body maximum opportunity to utilize its inherent recuperative powers. The success of Chiropractic procedures often depends on the environment, underlying causes, physical and spinal conditions. It is important to understand what to expect from Chiropractic health care services.

A patient, in coming to the Doctor of Chiropractic, gives the Doctor Permission and authority to care for the patient in accordance with Chiropractic tests, diagnosis and analysis. Chiropractic adjustments or other clinical procedures are usually beneficial and seldom cause any problem: In rare cases underlying physical defects, deformities or pathologies may render the patient susceptible to injury. The doctor will not give a chiropractic adjustment or treatment if he is aware that such care may be contracted. It is the sole responsibility of the patient to make it known to the doctor of any health care procedures that you have had as well as any defect, illness, or deformity you may be suffering from.

The purpose of Chiropractic Care is to promote natural health through the reduction of the VSS or VSC. Since there are so many variables, it is difficult to predict the time schedule or efficiency of the Chiropractic procedures as each individual person/case is unique to that patient. In most cases there is a more gradual, but a quite satisfactory response. Occasionally, the results are less than expected. Many medical failures find quick relief through Chiropractic. In turn, we must admit that conditions which do not respond to Chiropractic care may come under the control or be helped my medical science. The fact is that the science of Chiropractic and medicine may never be so exact as to provide definite answers to all problems. Both have great strides in alleviating pain and controlling disease.

Please discuss any questions or medical problems with the doctor prior to treatment.

I have read and understand the forgoing consent to treatment.

Insurance Assignment of Benefits and Instruction for Direct Payment

I herby instruct and direct my insurance company pursuant to F.5.627.422 to pay by check or draft made out to and mailed directly to the above-named provider for professional or medical services. And any reimbursements otherwise payable to me under my current insurance policy as payment toward total charges for professional services rendered by them. The payment is to not exceed my indebtedness to the above-named provider.

I herby assign all rights and benefits that | have under any Group Health, HMO plan, individual Health, Personal injury Protection: (PIP), IP, Disability, or any other Health or Medical plan or policy or reimbursement plan that may pay patient benefits for service and treatment that I have received or will receive from the above-named provider.

If my current policy prohibits direct payment to the doctor, then I herby instruct and direct you to make out the check payable to me and mail it to the office indicated above.

This assignment includes but is not limited to all rights to collect benefits directly from my insurance company or HMO for those services and treatments that | have received and all rights to proceed against my insurance company or HMO in any action including legal suit if for any reason my insurance company or HMO fails to make payments of benefits that are due to the above-named provider. This assignment also includes the right to recover any attorney fees and costs for such action brought by the provider as my assignee.

I also agree that the above-mentioned provider be given Power of Attorney to endorse/sign my name on any and all checks for the payment of services provided by them.

I understand that I am financially responsible for any balance not covered by my insurance company. All self-pay patients are expected to pay for services in full at the time services are rendered. Ultimately, payment responsibility rests with you the patient.

I also authorize the release of any information pertinent to my case or claim to the above-named provider or any attorney involved in this case. A photocopy of this assignment shall be considered as effective and valid as the original.

I herby authorize the above-named provider to file any informal complaints that are necessary to the Insurance Commissioner’s Office or agency or court they deem appropriate on my behalf.