PATIENT INTRODUCTION FORM
Welcome to our office! We want to thank you for choosing us to help you with your injuries or health problems.
Please be sure to fill out these forms completely, to read everything and sign where appropriate.
If you have been in a car accident, please let the front office staff know, and you will be given different, specific accident forms. If you are using your Health Insurance to pay for your treatment, please be sure to fill outEVERYTHING in the boxes below, and give your insurance card and driver’s license to the front office staff to make a copy for your file. Failure to fill out ALL information (except email address) and provide your card for copying will result in your insurance carrier denying your claim, which may leave you personally responsible for the charges for your treatment. Additionally, all of the following forms for your health history, informed consent, and HIPPA privacy policies must be filled out and signed in order to receive treatment and to justify medical necessity to your insurance carrier If you have any other questions about these forms, please ask our front office staff.
Please printCLEARLY and fill out ALL information
Patient Name: / Today's Date:Address: / Home phone:
City/State/
Zip Code: / Cell phone:
Work phone:
Date Birth: Age: / Employer’s Name:
Height: Weight: / Employer’s Address:
Social Security No: / Job Title:
Drivers License No:
Email address: / Marital Status (Circle one):
Single, Married, Divorced, Widowed
Name, Address, Relationship, and Telephone Number of your nearest adult relative (for emergencies):
______
Let us know how we may contact you or leave messages regarding your appointments/treatment:
May we contact you at work? Yes No circle one Leave message at work? Yes No circle one
May we contact you at home? Yes No circle one Leave message at home? Yes No circle one
May we contact you on your cell phone? Yes No circle one Leave message on cell? Yes No circle one
May we welcome you in our patient newsletter with your first and last name, and thank the person who referred you to us, and congratulate you if you are patient of the month in the future? Yes No circle one
INSURANCE INFORMATION
Does your insurance cover Chiropractic treatment? / Yes, No If yes, we need a copy of the cardAre you the insured person or dependent (wife/husband/child)? / Insured, Dependent
If you are the insured person’s dependent (spouse or child), we need the insured person’s name, date of birth, social security number, and the name of the insured’s employer. / Name of Insured Person:
Social Security Number:
Insured Date of Birth:
Name of Insured Company:
Have you met your deductible this year?
Do you have a secondary insurance? / Yes, No
Yes, No If yes, we need a copy of the card
Our office will provide insurance billing services for you if you so desire as a courtesy. Remember that you are ultimately responsible for any charges incurred in this office. It is your responsibility to pay any deductible amount, copay/co-insurance, and or any other balances not paid by your insurance carrier. For example, although you may have chiropractic benefits on your policy, your insurance company can decide to deny all or part of your treatment, even if they pre-authorize it. It is not fair or right, but that is how they operate. Your signature on this document indicates that you agree to pay for any outstanding bills incurred in this office.
IN ORDER TO KEEP OUR OFFICE OVERHEAD DOWN AND KEEP OUR PATIENT FEES REASONABLE, WE EXPECT PAYMENT AT THE CONCLUSION OF EACH TREATMENT FOR CASH PATIENTS AND THE CO-PAYMENT/DEDUCTIBLE FOR REGULAR INSURANCE PATIENTS.
Signature of responsible party (Patient or Parent): ______Date: ______
INFORMED CONSENT TO CHIROPRACTIC TREATMENT
Medical doctors, chiropractic doctors, osteopaths, and physical therapists who perform manipulation are required by law to obtain your informed consent before starting treatment.
I ______(PRINT your name), of ______(your city) do hereby give my consent to the performance of conservative noninvasive treatment to the joints and soft tissues. I understand that the procedures may consist of manipulations/adjustments involving movement of the joints and soft tissues. Physical therapy, massage, cold laser, nutritional recommendations, supplements, and exercises may also be used.
Although spinal manipulation/adjustment is considered to be one of the safest, most effective forms of therapy for musculoskeletal problems, I am aware that there are possible risks and complications associated with these procedures as follows:
Soreness: I am aware that like exercise it is common to experience muscle soreness in the first few treatments. I am also aware that after a massage I may also experience some soreness and in some cases bruising (especially if I am susceptible to bruising).
Dizziness:Temporary symptoms like dizziness and nausea can occur but are relatively rare.
Fractures/Joint Injury:I further understand that in isolated cases underlying physical defects, deformities or pathologies like weak bones from osteoporosis may render the patient susceptible to injury. When osteoporosis, degenerative disk, or other abnormality is detected, this office will proceed with extra caution.
Stroke:Although strokes happen with some frequency in our world, strokes from chiropractic adjustments are rare. I am aware that nerve or brain damage including stroke is reported to occur once in one million to once in ten million treatments. Once in a million is about the same chance as getting hit by lightening. Once in ten million is about the same chance as a normal dose of aspirin or Tylenol causing death.
Physical Therapy Burn or Reactions to adhesives:Some of the therapies used in this office generate heat and may rarely cause a burn. Despite precautions, if a burn is obtained, there will be a temporary increase of pain and possible blistering. This should be reported to the doctor. Some people may have sensitivities to adhesives used on electrodes or supportive taping. In some cases this can result in a rash. This should be reported to the doctor so that alternative methods can be used or that this therapy discontinued.
Tests have been performed on me to minimize the risk of any complication from treatment and I freely assume these above risks.
Treatment Results
I also understand that there are beneficial effects associated with these treatment procedures including decreased pain, improved mobility and function, and reduced muscle spasm. However, I appreciate there is no certainty that I will achieve these benefits.
I realize that the practice of medicine, including chiropractic, is not an exact science and I acknowledge that no guarantee has been made to me regarding the outcome of these procedures. I understand that the treatment plan that has been outlined to me is the doctor’s best estimate of how many treatments my condition may require, and that it not a firm number, as I may require more or less treatment.
I agree to the performance of these procedures by my doctor and any such other persons of the doctor’s choosing.
Alternative Treatments Available
Reasonable alternatives to these procedures have been explained to me including rest, home applications of therapy, prescription or over-the-counter medications, exercises and possible surgery.
Medications: Medication can be used to reduce pain or inflammation. I am aware that long-term use or overuse of medication is always a cause for concern. Drugs may mask pathology, produce inadequate or short-term relief, undesirable side-effects, physical or psychological dependence, and may have to be continued indefinitely. Some medications may involve serious risks.
Rest/Exercise: It has been explained to me that simple rest is not likely to reverse pathology, although it may temporarily reduce inflammation and pain. The same is true of ice, heat, or other home therapy. Prolonged bedrest contributes to weakened bones and joint stiffness. Exercises are of value but are not corrective of injured nerve and joint tissues.
Surgery: Surgery may be necessary for joint stability or serious disk rupture. Surgical risks may include unsuccessful outcome, complications, pain or reaction to anesthesia, and prolonged recovery.
Nontreatment: I understand the potential risks of refusing or neglecting care may include increases pain, scar/adhesion formation, restricted motion, possible nerve damage, increased inflammation, and worsening pathology. The aforementioned may complicate treatment making future recovery and rehabilitation more difficult
and lengthy.
I have read or have had read to me the above explanation of chiropractic treatment. Any questions I have had regarding these procedures have been answered to my satisfaction Prior To My Signing This Consent Form. I have made my decision voluntarily and freely.
To attest to my consent to these procedures, I hereby affix my signature to this authorization for treatment.
______Signature of patient
______Signature of witness
______Date and time
Notice of Patient Privacy Rights
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This office of is committed to protecting your personal medical information. This notice applies to the medical records maintained by this office and it specifically details the ways in which your medical information may be used and disclosed to third parties. This notice also details your individual rights regarding your medical records.
1. This office may use and/or disclose your medical information consistent with a valid consent granted by you for the purposes of: a) Treatment – In order to provide you with the healthcare you require, this office will provide your medical information to those healthcare professionals directly involved in your care so that they may understand your medical condition and needs. b)Payment – In order to get paid for services provided, this office will provide your medical information to appropriate third party payors, pursuant to their billing and payment requirements. Healthcare operations – In order to gain an overall view of various elements of this office’s operations, individual medical information may be collected, compiled and disseminated. For example, this office may utilize your medical information in order to evaluate the performance of our personnel in providing care to you.
2. This office may use and/or disclose your medical information, without a written consent from you, in the following instances: a. De-identified Information – Information that is not individually identifiable or that has had all personally identifying information removed, in accordance with applicable laws, may be freely disclosed by this office. B) Business Associate – If this office obtains satisfactory written assurance from the business associate, in accordance with applicable laws, that the business associate will appropriately safeguard the protected information. A business associate is an entity that assists this office in undertaking some essential function, such as a billing company that assists the office in submitting claims for payment to insurance companies or other payers; c) Personal Representative – If under applicable state law a person has the authority to represent you in making decisions related to your health care, information may be disclosed to that person without your written consent; d). For the purpose of obtaining or rendering emergency treatment to you, if the office attempts to obtain your consent but is unable to do so; e) To a public or private entity authorized by law or by its charter to assist in disaster relief efforts, for the purpose of coordinating your care with such entities in an emergency situation; f) Communication Barriers – If, due to substantial communication barriers or inability to communicate with you, this office has been unable to obtain your consent and this office determines, in the exercise of its professional judgment, that your consent to receive treatment is clearly inferred from the circumstances; g)Involvement in Care or Payment – member, other relatives, close personal friends and/or any other person identified by you, of such information that is relevant to the person’s involvement with your care or payment related to your health care; h) Notification – In order to notify or assist in the notification of a family member, a personal representative or another person responsible for your care of your location or general condition; i) Required by Law – When and to the extent that such disclosure is required by law, complies with and is limited to the relevant requirements of such law; j) Criminal Conduct – To a law enforcement official, that this office believes in good faith contributes evidence of criminal conduct that occurred on the office premises; k) Threat to Health and/or Safety – If it is necessary to prevent or lessen a serious and imminent threat to the health and/or safety of a person or the public, in accordance with applicable laws; l) Appointment Reminders, Treatment Alternatives and Health Related Benefits – In order to provide you with appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you. This office will send a postcard and/or call your home and/or leave a message on your answering machine or with any individual answering the phone as a reminder of your scheduled appointment with this office; m) Military and Veterans – If you are a member of the armed forces, as required by military command authorities; n) Worker’s Compensation – In order to provide information about you to worker’s compensation programs designed to provide benefits for work-related injuries; o)Public Health Risks – In order to prevent or control disease, injury and disability and to report child abuse or neglect; p) Health Oversight Activities – In order to provide information to a health oversight agency, such as your state Department of Health, for activities authorized by law, including inspections, investigations, audits and licensure; q) Lawsuits and Disputes – In order to comply with a court or administrative order in connection with a lawsuit or dispute; r) Coroners, Medical Examiners and Funeral Directors – In order to provide information to a coroner, medical examiner or funeral director for purposes of identification of an individual, the determination of the cause of death and for burial purposes; s) National Security and Intelligence Activities – In order to provide authorized governmental officials with necessary intelligence information for national security activities and purposes authorized by law. t) Fundraising – In order to conduct or assist business associates and/or other institutionally related foundations raise funds for a charitable purpose, such as a local hospital, the American Red Cross or other private or public disaster relief agency, Breast Cancer or AIDS-related research, etc., this office/practice may give out demographic information about you as well as any dates health care was provided to you without your consent or specific authorization. However, if this office/practice does engage in any fundraising activity, it must include instructions in the fundraising materials indicating how you may decline to receive any further fundraising communications from this office/practice.
Your Individual Rights – You have the right to: a. Revoke any authorization and/or consent, in writing, at any time – To request a revocation, please submit a written request to this office’s Compliance Officer, as set forth in Section 4(i) below;b. Request restrictions on certain uses and/or individuals or entities to whom we may make disclosures as provided by law; however, this office is not obligated to agree to any requested restrictions – To request restrictions, please submit a written request to this office’s Privacy Officer, as set forth in Section 4(i) below. In your written request, you must inform this office what information you want to limit, whether you want to limit this office’s use or disclosure, or both, and to whom you want the limits to apply. If this office agrees to your request, we will comply with the request unless the information is needed in order to provide you with emergency treatment;c) Receive confidential communications of protected health information as required by law – To request confidential communications, you must make your request in writing to this office’s Privacy Officer, as set forth in Section 4(i) below. We will accommodate all reasonable requests. Your request must specify how and where you wish to be contacted; d. Inspect and copy protected health information as provided by law – This right includes access to medical and billing records. To inspect and copy health information, please submit a written request to this office’s Privacy Officer, as set forth in Section 4(i) below. This office can charge you a fee for the costs of copying, mailing or other supplies associated with your request. This office may deny you access to medical information but you have the right to have this denial reviewed as will be set forth more fully in the written denial notice; e. Amend incorrect or incomplete protected information as provided by law – To request an amendment, please submit a written request to this office’s Privacy Officer, as set forth in Section 4(i) below. You must provide a rea-son that supports your request for the amendment(s). This office may deny your request if it is not in writing, if you do not provide a reason in support of your request, if the information to be amended was not created by this office (unless the individual or entity that created the information is no longer available), if the information is not part of the medical information maintained by the office, if the information is not part of the information you would be permitted to inspect and copy, and/or if the information is accurate and complete; f. Receive an accounting of disclosures (but not the uses) of protected information as provided by law – To request an accounting, please submit a written request to this office’s Privacy Officer, as set forth in Section 4(i) below. The request must state a time period which may not be longer than 6 years and may not include dates before April 14, 2003. The request should indicate in what form you want the list (such as a paper or electronic copy). The first list you request within a 12 month period will be free but this office may charge you for the costs of providing additional lists. This office will notify you of the costs involved and you can decide to withdraw or modify your request before any costs are incurred; g. To receive a paper copy of this notice from this office upon request to this office’s Privacy Officer, as set forth in Section 4(i) below;h. To complain to this office or to the Secretary of HHS if you believe your privacy rights have been violated. To file a complaint, please contact this office’s Privacy Officer, as set forth in Section 4(i) below. All complaints must be in writing; andi To obtain more information on, or have your questions about your rights answered, you may contact this office’s Compliance/Privacy Officer, at 626-338-3600 or via email at .