Welcome

We are pleased to welcome you to our practice! Please take a few minutes to tell us more about yourself.

Last Name______First______Initial______

Soc Sec#______

Address______City______State______Zip______

Home phone______Cell______E-mail______

Sex: M F Age_____Birth Date______Occupation______

Please circle: Single Married Widowed Separated Divorced

Employer______Work Phone______

Notify In Emergency______Phone______Relationship______

I give permission to release my info to (spouse, emergency contact, etc) ______

How did you hear of us?______

Primary Insurance

Person Responsible for Account______Relationship to Patient______

Address(if different from patient)______Birth Date of policy holder______

Soc Sec# policy holder______Insurance Company______

Do you have a secondary insurance?______Dependents on this plan______

Please provide a copy of your card.

Reason for Visit

Have you ever seen a chiropractor? Yes___ No___ If yes, when and why______

Your reason for this visit:______

Please tell us your current pain and location:______

When did your symptoms begin (date)?______Have you had similar conditions in the past?______

Is the pain getting___better___worse___same___varies. How often do you have this pain?______

Have you been treated by a medical physician for this condition?______

If so, who, where, and when?______

Is your pain: ___sharp___dull___aching___burning___tingling___cramping___throbbing___stiff___swollen____

Authorization

I have reviewed the information on both sides of this form and it is accurate to the best of knowledge. I understand that this information will be used by the chiropractor to help determine appropriate treatment. If there is any change in my medical status, I will inform my chiropractor. I authorize my insurance company to pay to the chiropractor all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions. I authorize the chiropractor to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.

Signature______Date______

Health History

Please list any medications you are taking______

______

Please list any serious injuries or surgeries you’ve had:

Falls______Date______

Head Injuries______Date______

Broken Bones______Date______

Dislocations______Date______

Surgeries______Date______

Other______Date______

Women: Pregnant?______If yes, how far along?______Nursing?______

Medical Conditions

Please circle any medical conditions that apply to you:

heartproblems/stroke arthritis ringing in ears ulcer/colitis

alcohol/drug abuse frequent neck pain sports injuries autoimmune disease

fainting/seizures jaw pain diabetes/tuberculosis shingles

wrist pain dizziness shoulder pain emphysema/glaucoma

arm pain kidney problems breathing problems leg pain

hepatitis pacemaker low back problems cancer

anemia severe/frequent headaches artificial joints HIV/AIDS

psychiatric problems other:______

numbness, where______tingling, where______muscle spasms, where______

Personal Habits

Heavy Moderate Light None

Alcohol

Caffeine

Tobacco

Drugs

Exercise

Sleep

Appetite

Who is your primary care physician?______

Initials______Date______

Wadsworth Chiropractic Financial Policy

  • Please be aware that ultimately it is the patient’s responsibility to know the limitations of their policy. We encourage patients to verify their benefits.
  • Co-pays are due at time of service as mandated by law.
  • Wadsworth Chiropractic will submit charges to you insurance company and our staff will assist with billing questions. Please be aware there are occasions that the patient may be requested to call their insurance company to clear up a billing issue.
  • If you have seen another chiropractor or physical therapist this year please inform us of how many visits you have used. We will keep count for you at our office, but failure to inform us of used visits at other locations may result in visit balances becoming your responsibility.
  • Failure to submit paperwork requested by your insurance company or Wadsworth Chiropractic may result in your balance becoming patient responsibility.
  • Statements will be sent directly to the patient once Wadsworth Chiropractic receives payment or explanation of benefits from the insurance company. Payment of the balance is due upon receipt unless arrangements have been made with our office. Balances over 30 days may be subject to an 18% annual interest or 1.5% per month.
  • Failure to respond from your insurance company may result in your account balance becoming patient responsibility. Insurance balances that have not been responded to within 60 days will be turned over to patient responsibility. We will make every attempt to work with the patient to reconcile any issues with their insurance company.
  • Wadsworth Chiropractic will follow treatment protocol as prescribed by the treating doctor. Your insurance company may deem services not medically necessary. Patients should be aware that charges may become patient responsibility.
  • Cash at time of service discounts are offered to both insured and uninsured patients. Services provided will be discounted to a set rate only if payment is rendered on the date of service. If payment is not received on the date of service then normal charges will be applied.
  • Wadsworth Chiropractic utilizes a collection agency for delinquent accounts. Wadsworth Chiropractic also utilizes small claims court for unresolved balances.
  • Wadsworth Chiropractic is certified by the State of Ohio as providers for the Bureau of Worker’s Compensation. Wadsworth Chiropractic will coordinate with the BWC and your Managed Care Organization to set up your care and billing. If services are deemed not medically necessary or your claim is denied then account balances may become patient responsibility. If a patient elects to appeal a denial then the balance become patient/private insurance responsibility and reimbursement back to the patient/private insurance will occur if the denial is overturned and payment made.
  • Wadsworth Chiropractic accepts personal injury claims. We will bill your med pay carrier for you. If you have an attorney, then a signed lien from the attorney is necessary. If the patient does not have a med pay rider or an attorney then we will bill the patient’s private insurance. If the patient does not have private insurance then cash at time of service discounts apply. Wadsworth Chiropractic is to receive payment upon distribution of funds/settlement of a claim. Failure to do so within 30 days will result is interest applied as described above.
  • Wadsworth Chiropractic abides by all local, state, and federal regulations.

I have read and understand the above information and by signing below agree to the policies set forth.

Patient (parent/guardian) signature:______

Date:______

Practice Privacy Requirements

The practice:

  1. Is required to maintain the privacy of your PHI and to provide you with this privacy notice detailing the practices’s legal duties and privacy practices with respect to your PHI.
  2. Under the privacy rule, the practice may be required by state law to grant greater access or maintain greater restrictions on the use or release of your PHIthan that which is provided for under federal law.
  3. The practice is requires to abide by the terms of this privacy notice.
  4. The practice reserves the right to change the terms of this privacy notice and to make the new privacy notice provisions effective for all your PHI that it maintains.
  5. The practice will distribute any revised privacy notice to you prior to implantation.
  6. The practice will not retaliate against you for filing a complaint.

Effective Date

This notice is effective as of 01-01-2009

Patient Acknowledgement

By signing my name below, I acknowledge the receipt of a copy of this notice and my understanding and my agreement to its terms.

Patient:______

Date:______

Permission is given to Wadsworth Chiropractic to release information to :

Spouse:______

Other:______

Wadsworth Chiropractic

Dr. Joseph Herbert Dr. Lisa Herbert

200 SmokeriseDr.,Suite 200

Wadsworth, Ohio 44281

P: 330-331-5320 F: 330-334-1828

CASH AT TIME OF SERVICE POLICY

____ I am choosing CASH AT TIME OF SERVICE. I understand that I am to pay a reduced rate of $60 on the initial day I receive services and $45 for follow up visits. I understand that this cannot be billed to my insurance or go towards my deductible. I understand that I can change my mind for future visits if I choose to use insurance. I understand that I cannot go back and change my mind for services already received.

____I am choosing to use my insurance. I understand that my insurance will be billed regular office charges and the cash at time of service reduction is not eligible for insurance billing. I understand that my insurance will pay a contracted amount depending on my policy and services may be applied to a deductible. I understand that Wadsworth Chiropractic is not told by my insurance company what the contracted amount is. I understand that I am responsible for the copay/coinsurance or deductible amount that my insurance company deems patient responsibility.

Patient Signature:______Date:______

Office Initials:______