First Name: Middle Initial: Last Name: Address Line 1: Address Line 2: Home Phone: ( ) - Work Phone: ( ) - Sex: Female Male Other
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1 Date: Bella Vita Chiropractic & Wellness 610 Eastbury Drive Suite 3 Iowa City, IA (319) Title: Mr. Mrs. Ms Miss First Name: Middle Initial: Last Name: Address Line 1: Address Line 2: City: State: Zip Code: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Date of Birth: / / Sex: Female Male Other Social Security Number: - - (Optional, used for insurance purposes.) Marital Status: Employment Status: Insurance Policy Holder's Data (unless same as above.) First Name: Middle Initial: Last Name: Policy Holder's Date of Birth: / / Address: Physician Information Physician s Name and phone number: (We will never contact your Physician without prior authorization.) Emergency Contact Information Contact Name: Relationship to patient: Contact Phone: ( ) -
2 Bella Vita Chiropractic & Wellness, Longevity Chiropractic, Conley Chiropractic 610 Eastbury Drive Suite 3 Iowa City, IA (319) Is it okay to call you at work? Yes No How did you hear about our clinic? Or who referred you? Family member Attorney Internet web site Friend Yellow Pages Physician Radio Employer Sign on building Health class Other (please specify): If you selected family member, friend, or physician please enter their name below: Medical Conditions: Arthritis Cancer Diabetes Heart Disease Hypertension Psychiatric Illness Skin Disorder Stroke Surgeries: Appendectomy Cardiovascular procedure Cervical disc procedure Hysterectomy Joint replacement Laminectomies Radical prostatectomy Transuretheral prostate surgery Allergies: Eggs Fish and Shellfish Milk or Lactose Peanut Soy Sulfites Wheat/Gluten Latex Social History: Caffeine used occasionally Caffeine used often Chew tobacco occasionally Chew tobacco often Drink alcohol occasionally Drink alcohol often Exercise not at all Exercise occasionally Exercise often Experience stress occasionally Experience stress often Smoke 1 pack or less per day Smoke more than 1 pack a day Wear seat belts always Wear seat belts never Wear seatbelts usually Family History: Arthritis (parent) Arthritis (sibling) Cancer (parent) Cancer (sibling) Cholesterol (parent) Cholesterol (sibling) Diabetes (parent) Diabetes (sibling) Heart problems (parent) Heart problems (sibling) High blood pressure (parent) High blood pressure (sibling) Psychiatric (parent) Psychiatric (sibling) Stroke (parent) Stroke (sibling) Thyroid (parent) Thyroid (sibling) Substance Use: Alcohol (past) Alcohol (present) Amphetamines (past) Amphetamines (present) Barbiturates (past) Barbiturates (present) Cocaine (past) Cocaine (present) Crystal Meth (past) Crystal Meth (present) Heroine (past) Heroine (Present) Marijuana (past) Marijuana (present) Male Children: Under 6 years Under 10 years Under 19 years Female Children: Under 6 years Under 10 years Under 19 years Occupational Activities: Administration Business owner Clerical/secretarial Computer user Construction Daycare/childcare Executive/legal Food service industry Health care Heavy equipment operator Heavy manual labor Home services Household Light manual labor Manufacturing Medium manual labor
3 Bella Vita Chiropractic & Wellness, Longevity Chiropractic, Conley Chiropractic 610 Eastbury Drive Suite 3 Iowa City, IA (319) By using the key below, indicate on the body diagram where you are experiencing the following symptoms: # = Numbness X = Burning / = Stabbing 0 = Pins & Needles + = Dull Ache Describe your symptoms: When did your symptoms start? Month Day Year How did your symptoms begin? Other Health Concerns: Please list your current medications and/or supplements:
4 Patient Health Information Consent Form Bella Vita Chiropractic & Wellness, Longevity Chiropractic, and Conley Chiropractic 610 Eastbury Drive Suite 3 Iowa City, IA (319) 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 PHI 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 affect 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. Name of Patient Date
5 Bella Vita Chiropractic & Wellness, Longevity Chiropractic, and Conley Chiropractic 610 Eastbury Drive Suite 3 Iowa City, IA Informed Consent The primary treatment used by doctors of chiropractic is the spinal manipulation or spinal adjustment. The nature of the chiropractic adjustment/manipulation: The doctor will use his/her hands or a mechanical instrument upon your body in such a way as to move your joints. This adjustment my cause an audible pop or click much like when you crack your knuckles. You may or may not feel or sense movement. The doctor may also choose to provide therapy including muscle massage, ultrasound, electrical muscle stimulation or cold laser therapy. The material risks inherent in chiropractic adjustments/manipulations: As with any healthcare procedure, there are certain effects or complications which may arise. These complications can include fracture, disc injuries, muscle strains, cervical myelopathy (compression of the spinal cord), injuries of ribs, and soreness or stiffness after treatment. Some types of manipulation of the neck have been associated with injuries of the arteries in the neck leading to or contributing to serious complications including stroke. The probability of risks occurring: Fractures, disc, rib injuries, and cervical myelopathy are rare occurrences and generally result from some underlying condition or weakness. The doctor makes every attempt to become aware of these during the taking of your history and during examination. Injuries to arteries and stroke caused by chiropractic manipulation of the neck have been the subject of ongoing research and debate in the medical community. The most current research on the topic is inconclusive. There are types of manipulation that are least likely to be associated with these injuries. Upon your request the doctor will discuss these in detail. At all times the doctor will choose treatments that minimize the risk of discomfort and injury while providing the greatest benefit for your condition. DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE. I have read or have had read to me the above explanation of the chiropractic and adjustment and related treatment. I have discussed it with Dr. Jordan M. DeGrazia or Dr. Spencer Brink or Dr. Maria Conley and have had my questions answered to my satisfaction. By signing below I state that I have weighed the risks involved in undergoing treatment and I have decided that it is in my best interest to undergo the treatment recommended. Having been informed of the risks, I hereby give my consent to receive care. Date: Printed Name: Signature: Signature of Parent or Guardian:
6 Bella Vita Chiropractic & Wellness Longevity Chiropractic Conley Chiropractic Financial Policy I have read and understand the payment policy of Bella Vita Chiropractic & Wellness, Longevity Chiropractic, and Conley Chiropractic. I understand that my insurance is an arrangement between myself and my insurance company, NOT between Bella Vita Chiropractic & Wellness or Longevity Chiropractic or Conley Chiropractic and my insurance company. I request that Bella Vita Chiropractic & Wellness or Longevity Chiropractic or Conley Chiropractic prepare the customary forms at no charge so that I may obtain insurance benefits. I also understand that if my insurance does not respond within 60 days or if I suspend or terminate my schedule of care as prescribed by Dr. DeGrazia at Bella Vita Chiropractic & Wellness or Dr. Brink at Longevity Chiropractic or Dr. Conley at Conley Chiropractic that fees will be due and payable immediately. Patient's signature (or guardian if patient is a minor Date Witness Chiropractic care is covered under many insurance plans. We ask that you read and understand our policy as it applies to your particular situation.
7 PATIENTS WITHOUT INSURANCE Bella Vita Chiropractic & Wellness, Longevity Chiropractic, and Conley Chiropractic offer a 20% Time of Service Reduction in payment for 1hose patients without coverage. We are happy to accept cash. check. Master Card, Visa or Discover. GROUP OR INDIVIDUAL INSURANCE Bella Vita Chiropractic & Wellness, Longevity Chiropractic, and Conley Chiropractic are participating providers for Blue Cross Blue Shield PPO plans and several other commercial plans. Conley Chiropractic is participating provider for Blue Cross Blue Shield HMO plans. Coverage. co-payments, co insurance and deductibles vary with each plan. We will attempt to verify your coverage and patient responsibility al the time of your visit. However, the benefits quoted to us by your insurance company are not a guarantee of payment. Payment will be due by you at the time of service for any non-covered services. deductibles. co-pays or co-insurance. Any questions concerning your coverage may be directed co your insurance company. For those insurance plans in which we do not participate, you may want to verify if you qualify for out-of-network benefits by contacting your insurance company. ' ON THE JOB" INJURY (Worker's Compensation) Employers typically have authorized practitioners that work with their worker's compensation insurance company. You will need to contact your employer to find out their specific protocol. If Bella Vita Chiropractic & Wellness or Longevity Chiropractic or Conley Chiropractic is approved to provide care. you will need to provide us with the name and address of the insurance carrier and/or adjuster. guarantee of payment. Notify our insurance department immediately of the insurance infom,ation needed for billing and if an attorney is representing you. Although you are ultimately responsible for your bill, we will wait for the settlement of your claim for up to six months after your care is completed. Once the claim is settled or if you suspend or terminate care, any fees for services are due immediately. SECONDARY INSURANCE Please inform us of any secondary insurance you may have. We will assist you if you need help in filing. MEDICARE Bella Vita Chiropractic & Wellness and Longevity Chiropractic do not accept assignment from Medicare. Any insurance reimbursement is sent directly to our patients. You are required to pay the deductible as well as the limiting charge and any non-covered services at time of service. Our office completes and files the claims for Medicare at no charge. Conley Chiropractic does accept assignment from Medicare. You are required to pay your copay each visit. Our office completes and files the claims for Medicare at no charge. MEDICAID Bella Vita Chiropractic & Wellness, Longevity Chiropractic, and Conley Chiropractic do not participate with Medicaid of Iowa or any other state. PERSONAL INJURY OR AUTOMOBILE ACCIDENTS Please notify your auto insurance carrier of your visit to our office immediately. The benefits quoted by the insurance company are not a
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Describe the pain and it s location:
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