PATIENT FINANCIAL ACKNOWLEDGEMENT
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- Dwain Bond
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1 PATIENT FINANCIAL ACKNOWLEDGEMENT Please read thoroughly. Initial your acknowledgement, then sign and print your name and date. Thank you. ASSIGNMENT OF BENEFITS I assign all benefits payable to me for my care at Northwestern Health Sciences University. I understand that this health care facility will be paid directly by the insurance company or other payer. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is considered as valid as the original. GUARANTEE OF PAYMENT I guarantee payment of all charges incurred for treatment in accordance with the rates and terms of this health care facility. CANCELLATION POLICY To maintain our excellence in customer service and to acknowledge the student intern s time and patient requirement, we require a 24- hour cancellation notification for our student and professional acupuncture, massage, naturopath, nutrition, and Oriental medicine appointments. Please notify the clinic within 24 hours to avoid a $20 charge for the missed appointment. SIGNATURE (PATIENT GUARDIAN ) PRINT NAME DATE United Health Care Medica Preferred One Landmark/CCMI (Health Partners, Cigna, Patient Choice) Office Use Only Medicare Medical Assistance Select Care BCBS CHIROPRACTIC ACUPUNCTURE NURSE PRACTITIONER 1. Deductible/co-insurance? 2. Is there a co-pay? $ 3. Limit on visits or services? 992XX (Examination) (Therapeutic exercise) (NMS re-education) 1. Deductible/co-insurance? 2. Co-pay? $ 3. Limit on visits or services? 4. Authorization/Precertification needed? ACUPUNCTURE BENEFITS NOT VERIFIED 1. Deductible/co-insurance? 2. Co-pay? $ EXTRA SPINAL MANIPULATION LABORATORY Orthotics # per year Orthotics NOT verified Radiology non-spinal Radiology-spinal STRAPPING (Hot/cold packs) (EMS Attended) (Ultrasound) S8948 (Cold laser) (Mechanical Traction) ACUPUNCTURE NOT A BENEFIT ON THIS PLAN BASED ON THE INFORMATION PROVIDED BY THE HEALTH INSURANCE PLAN, SERVICES CHECKED ABOVE ARE NOT COVERED. Northwestern Health Sciences University 2501 W. 84 th St. Bloomington, MN
2 NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT AND CONSENT The Northwestern Health Sciences University (NWHSU) Care Delivery System is committed to patient privacy and the confidentiality of personal health information entrusted to us. The ways in which we may use or disclose your health information are detailed in the Notice of Privacy Practices. Your Right to Limit Uses or Disclosures: You have the right to request that we do not disclose your health information to specific individuals, companies, or organizations. If you would like to place any restrictions on the use or disclosure of your health information, we will provide you with a Limitation of Use and Disclosure of Protected Health Information Request form. Your Right to Request that Your Patient Record be Amended: You have the right to request that we amend the information in your patient record. If you would like to amend any information in your record we will provide you with a Request to Amend Protected Health Information form. Your Right to Revoke Your Authorization: You may revoke any of your authorizations at any time; however, your revocation must be in writing. We will not be able to honor your revocation request if we have already released your health information before we receive your request to revoke your authorization. If you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they decide to contest any of your claims. YOU HAVE A RIGHT TO REFUSE CONSENT FOR DISCLOSURE OF YOUR PERSONAL HEALTH INFORMATION. WITHOUT YOUR CONSENT, HOWEVER, THE NWHSU-CLINIC SYSTEM WILL NOT BE ABLE TO SUBMIT CLAIMS TO INSURANCE CARRIERS OR OTHER THIRD PARTY PAYERS AND MAY NOT ACCEPT YOU AS A PATIENT/CLIENT. Initial here [ ] I acknowledge receipt of the NWHSU-Notice of Privacy Practices By signing below, I give consent to the NWHSU-clinicians or staff to use or disclose my personal health information as noted in the Notice of Privacy Practices. Printed Name Authorized Provider Representative Signature Northwestern Health Sciences University 2501 W. 84 th St. Bloomington, MN
3 PATIENT INTAKE FORM Patient s Name: Patient s Guardian Name (if applicable): Address: (LAST, FIRST, MIDDLE INITIAL) of Birth: Phone: Gender: M / F Primary Healthcare Provider and/or Clinic: Please tell us who you were referred by so we may thank them: Physician: Marital status? (Please check most current status) Single Married Living with Significant Divorced/Separated Widowed Are you being seen for: Motor Vehicle Accident Workers Compensation (friend/family/patient): What is your race? (Defined by the federal government; please check one) Asian or Pacific Islander Black/African American Hispanic American Indian or Alaskan Native White What is the reason for your visit today? Was there a triggering event? How long have you had the problem? What do you want your treatment to accomplish? Please indicate where you have pain or other symptoms below: Please list any significant traumas or injuries you have had: NUMBNESS ===== PINS & NEEDLES BURNING XXXXX STABBING ////// ACHING **** Patient/Guardian Signature
4 PATIENT REVIEW OF SYSTEMS Please check the Current box for all conditions that you are now experiencing and mark the box for any condition or symptom(s) experienced previously. Please do not write in the spaces marked. Current Please do not write in this space. Current Please do not write in this space. GENERAL LUNGS Fever Difficulty breathing Sweats Asthma Chills Pneumonia Fatigue Wheezing Weight loss/gain Persistent cough Sleep disturbance Coughing up phlegm Change in routine Coughing up blood HEAD Tuberculosis Headache CARDIO VASCULAR Dizziness Chest pain Head trauma Palpitations Fainting Ankle swelling Blacking out Cold/hot feet or hands EYES Discolored foot/hand Change in vision Leg cramps/calf pain Glasses/Contacts Varicose veins Blurry/double vision High/l ow blood pressure Cataracts G-I SYSTEM Sensitive to light Gas Flashes in vision Heartburn/Indigestion Spots in vision Ulcers EARS Vomiting/Nausea Ringing in ears Abdominal pain Frequent infection Diarrhea/constipation Hearing loss Blood in stool Drainage Hemorrhoids Ear pain Gall bladder disease NOSE Liver disease Post nasal drip Colonoscopy Nosebleeds G-U SYSTEM Sinus problems Difficulty urinating MOUTH Pain urinating Bleeding gums Blood in urine Cold sores Incontinence Dentures Foul odor of urine Trouble Swallowing Increase/decreased urination Sore throat Urinary infection Jaw pain Genital infection Changes in taste Kidney stones Swelling Last prostate exam (males) Hoarseness Last PSA (males) Last dental appt Last testicular exam (males) MEDICAL MEDICATION Substance abuse Prescription medications (please bring) Hospitalization OTC medication (please bring) Psychiatric care Vitamins (please bring) Surgeries Herbs Last chest x-ray (for those over age 55) Drug allergies Copyright 2012 Best Practices Academy, LLC
5 Current Please do not write in this space. PSYCHOLOGIC NECK Excessive Stress Masses Depression Swelling Anxiety Stiffness Mood swings SOCIAL SKIN Consume alcohol Rash Consume caffeine Bruising Tobacco use Hair loss Recreational drugs Brittle nails Exercise Y N Changes in moles Safe at home Y N Itching/peeling Guns at home Y N NEUROLOGIC Seat belts used Y N Seizures/Epilepsy Text while driving Y N Strokes Hobbies Tingling/numbness Drink glasses water/day Weakness Sleep hours/night Difficulty walking Occupation Poor coordination OB GYN (females) MUSCLE/BONE Pregnancy Osteoporosis Breast cancer Joint pain Lumps in breast Stiffness Nipple discharge Muscle ache PMS Arthritis Irregular periods Deformity Hot flashes Bone pain Menopause Dislocations Menstrual cramps Fractures (please list): Age period began LABORATORY Last breast exam Last fasting blood glucose (date) Last PAP Last cholesterol (date) Last mammogram VACCINATIONS (if age >60 y/o) PAST MEDICAL HISTORY Flu Allergies Varicella Hypertension Pneumonia Diabetes Tetanus Cancer/Tumor FAMILY HISTORY (immediate family members) Anemia Cancer Alcoholism Depression Epilepsy Alzheimer s Heart Disease Current Please do not write in this space. Patient Name Patient Signature Clinician s Name Copyright 2012 Best Practices Academy, LLC
6 Patient Medications & Supplements List Patient Name Patient ID Allergies (include medication, food and environmental) Medication Name (include prescribed drugs, OTC drugs, herbs & supplements) Prescribed By Dosage & Frequency Reason for Taking
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CLAYTON PARK CHIROPRACTIC CENTRE INC. Suite 11-117 Kearney Lake Road Halifax, Nova Scotia B3M 4N9 (902) 443-5669 phone (902) 443-9419 fax info@claytonparkchiro.ca For Office Use Only: Bilaterals L R PERSONAL
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