CHIROPRACTIC INFORMED CONSENT

Transcription

1 CHIROPRACTIC INFORMED CONSENT I hereby give my consent to the performance of diagnostic tests and procedures and chiropractic treatment or management of my condition(s). I understand that the treatment I receive at this clinic may be performed by advanced chiropractic interns under the supervision of a licensed Doctor of Chiropractic. I also understand that this is a teaching clinic and that student observers may be present during treatment. Chiropractic treatment or management of conditions almost always includes the chiropractic adjustment, a specific type of joint manipulation. Like most health care procedures, the chiropractic adjustment carries with it some risks. Unlike many such procedures, the serious risks associated with the chiropractic adjustment are extremely rare. Following are the known risks: Temporary soreness or increased symptoms or pain It is not uncommon for patients to experience temporary soreness or increased symptoms or pain after the first few treatments. Dizziness, nausea, flushing These symptoms are relatively rare. It is important to notify the chiropractor if you experience these symptoms during or after your care. Fractures When patients have underlying conditions that weaken bones, like osteoporosis, they may be susceptible to fracture. It is important to notify your chiropractor if you have been diagnosed with a bone weakening disease or condition. If your chiropractor detects any such condition while you are under care, you will be informed and your treatment plan will be modified to minimize risk of fracture. Disc herniation or prolapse Spinal disc conditions like bulges or herniations may worsen even with chiropractic care. It is important to notify your chiropractor if symptoms change or worsen. Stroke A certain extremely rare type of stroke has been associated with chiropractic care. Although there is an association between this type of stroke and chiropractic visits, there is also an association between this type of stroke and primary care medical visits. According to the most recent research, there is no evidence of excess risk of stroke associated with chiropractic care. The increased occurrence of this type of stroke associated with both chiropractic and medical visits is likely explained by patients with neck pain and headache consulting both doctors of chiropractic and primary care medical doctors before or during their stroke. Other risks associated with chiropractic treatment include rare burns from physiotherapy devices that produce heat. Bruising Instrument assisted soft tissue manipulation may result in temporary soreness or bruising. I understand that the practice of chiropractic, like the practice of all healing arts, is not an exact science, and I acknowledge that no guarantee can be given as to the results or outcome of my care. PATIENT PLEASE REVIEW PRINT & SIGN NAME I have read or had read to me this informed consent document. I have discussed or been given the opportunity to discuss any questions or concerns with my chiropractor and have had these answered to my satisfaction prior to my signing this informed consent document. I have made my decision voluntarily and freely. PATIENT S NAME (Print) DATE OF BIRTH (PATIENT GUARDIAN SIGNATURE) (DATE) (TRANSLATOR INTERPRETER SIGNATURE) (DATE) (if applicable) CLINICIAN ONLY Based on my personal observation and the patient s history, I conclude that throughout the informed consent process the patient was: OF LEGAL AGE APPEARS UNIMPAIRED CONSENT GIVEN THROUGH GUARDIAN INTERN PRESENT - INITIALS ORIENTED X3 FLUENT IN ENGLISH ASSISTED BY A TRANSLATOR OR INTERPRETER INTERN NOT PRESENT, D.C. (D.C. SIGNATURE) (DATE) Northwestern Health Sciences University 2501 W. 84 th St. Bloomington, MN

2 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 Other 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

3 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 Date Date Northwestern Health Sciences University 2501 W. 84 th St. Bloomington, MN

4 PEDIATRIC PATIENT INTAKE FORM Patient s Name: Date of Birth: Patient s Guardian Name: Address: (LAST, FIRST, MIDDLE INITIAL) Phone: Gender: M / F Primary Healthcare Provider and/or Clinic: Please tell us who you were referred by so we may thank them: Physician: Are you being seen for: Motor Vehicle Accident Workers Compensation Other (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 Other What is the reason for your visit today? Was there a tiggering event? How long has the problem persisted? Please indicate the area of pain or other symptoms below: Please list any significant traumas or injuries you have had: NUMBNESS ===== PINS & NEEDLES BURNING XXXXX STABBING ////// ACHING Other ****

5 PREGNANCY Please check any areas that applied to the patient s mother during her pregnancy: Complications Excessive Weight Loss Excessive Weight Gain Bleeding Premature Contractions Back Pain Toxic Exposures Allergic Reactions Mental Trauma Physical Injury Vitamins/Minerals Medications Any diagnosed Illnesses Hospitalization Immunization Prenatal Classes Chiropractic Care Prenatal Care Carried to Full Term Attitude Mostly Happy Attitude Mostly Depressed Recreational drugs Smoking Alcohol Caffeine (Cola/Coffee/Tea) LABOR AND DELIVERY _ Home Birth Forceps Medications (list below) Hospital Vacuum Extraction 1. Greater than 12 Hours Fetal Monitor Used 2. Less than 5 hours Caesarian 3. Complications Premature Delivery 4. Other PERINATAL HISTORY If known please indicate The duration of the pregnancy was weeks. The apgar score at birth was The apgar score at five minutes was The length at birth was The birth weight was Please check any problems the patient had at birth Breathing Nursing _ Choking Jaundice Coloring Sleeping Crying IMMUNIZATION Other (please explain) Please check if any item(s) applied to the patient at birth: Medication Surgery Artificial Feeding Erythromyocin Vitamin K Circumcision Other (please explain) Please check if the patient has received any of the following items: Breast milk Commercial Formula Cow s milk Goat milk Solid food Sweets Fruit juice Vegetable juice Vitamins Medications Other Please list immunizations, date received and any reactions: Note foreign travel: Patient/Guardian Signature Date

6 Current Past Current Past Clinician s Notes Only Please do not write in this space. PATIENT REVIEW OF SYSTEMS Please check the Current box for all conditions that you are now experiencing and mark the Past box for any condition or symptom(s) experienced previously. Please do not write in the spaces marked Clinician s Notes Only. Clinician s Notes Only 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

7 Current Past Current Past Clinician s Notes Only Please do not write in this space. Clinician s Notes Only 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 Other Alcoholism Depression Epilepsy Alzheimer s Heart Disease Other Patient Name Date Patient Signature Clinician s Name Copyright 2012 Best Practices Academy, LLC

8 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

9 Name Date: Body area: What was the typical level of your pain the past week? If you don t have pain please circle zero. (Circle only one number)