-Who is responsible for this account? _

Transcription

1 CHIROPRACTIC REGISTRATION AND HISTORY j] PATIENT INFORMATION Dffie ~ INSURANCE INFORMATION Who is responsible for this account? SS/HIC/Patient 10 # Relationship to Patient Patient Name ;::::;:..::= Last Name Insurance Co. Group# Address City First Name Middle Initial State Zip Sex 0 M 0 F Age Birthdate o Married o Separated Patient Employer/School Occupation o Widowed o Single o Minor o Divorced o Partnered for years Employer/School Address Employer/School Phone ( ) Spouse's Name Is patient covered by additional insurance? 0 Yes 0 No Subscriber's Name Birthdate SS# Relationship to Patient Insurance Co. Group# ASSIGNMENT AND RELEASE I certify that I, and/or my dependent(s), have insurance coverage with =;c;..;.; Name of Insurance Company(ies) and assign directly to Dr. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The abovenamed doctor may use my health care Information and may disclose such information to the abovenamed Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below. Birthdate SS# Signature of Patient, Parent, Guardian or Personal Representative Spouse's Employer Please print name of Patient, Parent, Guardian or Personal Representative Whom may we thank for referring you? Date Relationship to Patient c;'s) PHONE NUMBERS Cell Phone ( ) Home Phone ( ) Best time and place to reach you IN CASE OF EMERGENCY, CONTACT Name Relationship Home Phone ( Work Phone ( "J:!J ACCIDENT INFORMATION Is condition due to an accident? 0 Yes 0 No Date Type of accident 0 Auto 0 Work 0 Home 0 Other To whom have you made a report of your accident? o Auto Insurance 0 Employer 0 Worker Compo 0 Other Attorney Name (if applicable) PATIENT CONDITION When did your symptoms appear? Is this condition getting progressively worse? 0 Yes 0 No 0 Unknown Mark an X on the picture where you continue to have pain, numbness, or tingling. Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain) Type of pain: 0 Sharp 0 Dull 0 Throbbing 0 Numbness 0 Aching 0 Shooting o Burning 0 Tingling 0 Cramps 0 Stiffness 0 Swelling 0 Other How often do you have this pain? Is it constant or does it come and go? Does it interfere with your 0 Work 0 Sleep 0 Daily Routine 0 Recreation Activities or movements that are painful to perform 0 Sitting 0 Standing 0 Walking 0 Bending 0 Lying Down (Vers.C2SSS04) 0 V E R #20572 c 2004 Medical Arts Press '

2 JI:l HEALTH HISTORY ~ ~ What treatment have you already received for your condition? 0 Medications o Surgery o Physical Therapy o Chiropractic Services DNQne o Other Name and address of other doctor(s) who have treated you for your condition Date of Last: Physical Exam Spinal XRay Blood Test Spinal Exam Chest XRay Urine Test Dental XRay MRI, CTScan, Bone Scan Place a mark on "Yes"or "No" to indicate if you have had any of the following: AfDS/HIV DYes DNa Diabetes DYes DNa Liver Disease DYes DNa Rheumatic Fever DYes DNa Alcoholism DYes DNa Emphysema DYes DNa Measles DYes DNa Scarlet Fever DYes DNa Allergy Shots DYes DNa Epilepsy DYes DNa Migraine Headaches0 Yes DNa Sexually Anemia DYes DNa Fractures DYes DNa Miscarriage DYes DNa Transmitted Disease DYes DNa Anorexia DYes DNa Glaucoma DYes DNa Mononucleosis DYes DNa Stroke DYes DNa Appendicitis DYes DNa G6iter DYes DNa Multiple Sclerosis DYes DNa Suicide Attempt DYe.s DNa Arthritis DYes DNa Gonorrhea DYes DNa Mumps DYes DNa Thyroid Problems DYes DNa Asthma DYes DNa Gout DYes DNa. Osteoporosis DYes DNa Tonsillitis DYes DNa Bleeding Disorders DYes DNa Heart Disease DYes DNa Pacemaker DYes DNa Tuberculosis DYes DNa Breast Lump DYes DNa Hepatitis DYes DNa Parkinson's Disease 0 Yes DNa Tumors, Growths DYes DNa Bronchitis DYes DNa Hernia DYes DNa Pinched Nerve DYes DNa Typhoid Fever DYes DNa Bulimia DYes DNa Herniated Disk DYes DNa Pneumonia DYes DNa Ulcers DYes DNa Cancer DYes DNa Herpes DYes DNa Potie DYes DNo Vaginal Infections DYes DNo Cataracts DYes DNa High Blood' Prostate Problem DYes DNa Pressure DYes DNa Whooping Cough DYes DNa Chemical Prosthesis DYes DNa Dependency DYes DNa High Cholesterol DYes DNo Other PsychiatricCare DYes DNa Chicken Pox DYes DNa Kidney Disease DYes DNa RheumatoidArthritis 0 Yes DNa, EXERCISE WORK ACTMTY HABITS o None o Sitting o Smoking Packs/Day o Moderate o Standing o Alcohol Drinks/Week o Daily o Light Labor o Coffee/Caffeine Drinks Cups/Day o Heavy o Heavy Labor o High Stress Level Reason Areyou pregnant? DYes DNa Due Date Injuries/Surgeries you have had Description Date Falls Head Injuries Broken Bones Dislocations Surgeries 7l,.. MEDICATIONS ALLERGIES VITAMINS/HERBS/MINERALS Pharmacy Name Pharmacy Phone (:j. <.

3 CHILD PATIENT INFORMATION SHEET ABOUT YOUR CHILD Today's Date'' Child's Name Nickname Reasonfor Visit Sex M F (circle one) Birth weight Length Age sat up Stood up Age walked 1 st spoke 1 st tooth Toilet trained Formula Y N Breast fed Y N Vitamins Y N Floride Y N FAMILY INFORMATION Birth date '' Age Grade School SS# Parent's marital status (please circle) Single Married Divorced Widow Separated Child's Address Mother's ncime Child's Phone# WHO IS ACCOMPANYING THE CHILD TODAY? Name Relationshipto child Are you the child's legal guardian? Biological Stepmother Guardian Adopted Mother's health Good Fair Poor Birth date'i HomePhone# ~ Employer Work Phone # SS# CHILD'S MEDICAL HISTORY List any allergies List medications Vitamin supplements Hasyour child had any of the following? Measles/ German Measles ' Chicken Pox ' MumpsI Pneumonia, List any diseases (Ex: diabetes, asthma, heart, etc.) Father's Name Biological $t e pd a d Guardian Adopted Father's health Good Fair Poor, Birth date'! HomePhone# Employer ~ Work Phone # SS# Who is responsible for making child's appointments? Mother Father Child Please list any other children, with birth dates and genders

4 CONSENT TO TREATMENT OF A MINOR As my child's parent and/or legal guardian, I hereby authorize Chase Chiropractic professional staff to administer treatment as they deem necessary to my (son/daughter), (minor's name). and its In the event that diagnostic xrays are advisable in this case, so that a complete analysis can be made of the present musculoskeletal problem or illness, authorization is granted for such radiographic examination to be performed in order to treat this case. This authorization will permit administration of treatment as deemed necessary to treat the present problem as well as any problem or illness that may occur in the future. Parent/guardian signature Date // Witness Date /1 INSURANCE INFORMATION Primary insurance Company Companyname Address. Customer Service Phone # 10 # Group # Policy holder's name Birth date / / In the event of an emergency, who should we contact? Name Relationship Home phone# Work phone # ACCOUNT INFORMATION Person ultimately responsible for account Name Relationship, Billing address We invite you to discuss frankly with us any questions regarding our services. Our office policy requires payment at time of visit unless services are billed to your insurance company. If your company rejects the claim, you must pay for the service and settle any dispute with your insurance company yourself. Unless other arrangements are made, the person bringing the patient to this office is responsible for the charges. Accounts 90 days past due, with. no financial arrangement with this office, will be sent to collection. I hereby authorize payment of benefits directly to provider. I further authorize the physician to release any information required to process insurance claims., I understand the above information and guarantee this form is completely correct. Signature of responsible party nate II

5 MISSED APPOINTMENT POLICY We ask for your assistance and cooperation in keeping your scheduled appointment date and time. It is our policy that if a patient misses or cancels an appointment with less than 24 hours notice, that patient will be charged a $25.00 fee (subject to change) for that time slot. This policy is necessary to avoid the numerous scheduling problems that lastminute cancellations and missed appointments create. If a need arises to cancel or change your appointment, please give us a minimum of 24 hours notice. We thank you for your cooperation maintenance. and look forward to being a vital part of your recovery and Signature Date

6 Chase Chiropractic (586) n FAX: (586) n Harper Ave. st, Clair Shores, MI Center DR. PATRICK CHASE Chiropractor Informed Consent to Chiropractic Care I hereby request and consent to the performance of chiropractic manipulation or adjustments and other chiropractic procedures, including various modes of physical therapy or physical medicine procedures, and diagnostic xrays, on me (or on the patient named below for whom I am legally responsible) by the doctor of chiropractic named below and/or other licensed doctors of chiropractic who now or in the future treat me while employed by, working or associated with or serving as backup for the doctor of chiropractic named below. I have had an opportunity to discuss with the doctor of chiropractic named below and/or with other office or clinic personnel the nature and purpose of chiropractic manipulations or adjustments and other procedures. I understand that results are not guaranteed. I understand and am informed that, as in the practice of medicins, in the practice of chiropractic there are some risks to treatment, including, but not limited to, fractures, disc injuries, strokes, dislocations, and sprains. I do not expect the doctor to be able to anticipate and explain all possible risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure, which the doctor feels at the time, based upon the facts then known, is in my best interest.. 1 I have read, or have had read to me, the above consent I have also had an opportunity to ask questions about its content, and by signing below I agree to the above named procedures. I intend this consent form to cover the entire course of treatment for my present condition. Signature of Patient: Date: To be completed by the patient's representative, if necessary, e.q., if patient is a minor or physically or otherwise legally incapacitated. Signature of Patient's Representative: 1 Date: :;

7 CHASe CHIROPRACTIC CENTER HARPER AVE. ST CLAIR SHORES, MI Electronic Health Records Intake Form In compliance with requirements for the government EHR incentive program First Name: Last Name: Preferred method of communication for patient reminders (Circle one): /Phone / Mail 008: jj Gender (Circle one): Male / Female Preferred Language: Smoking Status (Circle one): Every Day Smoker / Occasional Smoker / Former Smoker / Never Smoked ems requires providers to report both race and ethnicity Race (Circle one): American Indian or Alaska Native / Asian / Black or African American / White (Caucasian) Native Hawaiian or Pacific Islander / Other / I Decline to Answer Ethnicity (Circle one): Hispanic or Latino / Not Hispanic or Latino / I Decline to Answer Are you currently taking any medications? (Please include regularly used over the counter medications) Do you have any medication allergies? o reheese to decline receipt of my clinical summary after every visit (These summaries are often blank as a result of the nature and frequency of chiropractic care.) =':or. )ff\ J'St:: ONL'{ Date:

8 Co~;;ntf"orPurposes of Treatmen~ Payment and Healthcare O~n5 I ~e that Chase Chiropractic ~& Notice of Privacy prac;r;ces. has been" pro\lidecl to me. ' " ". I understand I have"a right to "review Chase c~praetic Cen~$ NotiCe of ~ Practices prior to signing this document. ChaSe Cbi;QPractic:"Ce~s NotiGe of Privacy Practices has been provided to me. The Nonee of Privacy Pract:lcei;; de&cribes ~ ~ of uses and disclosures of my 'protected health information that will occur in my ~ payment of my bills orin the performance of health care operations of Cbase Ch~C:. Center. The Notice of Privacy Practices for "Chase Chiropranc; Cent.er is also"ptovided " on request at the main administration desk of this practice. No~ cf Privacy Pradices also "d~ my"~ts and Ch~ ~~irqpragtic: een... s duties with respect te my protected heatth information. ". " ', Chase CtUropractic, Center 'reserves the right to change the privacy practices tnat are described in the Notice of Privacy PracticeS. I may obtain a revised notice of" ~ prac:tices by calling the office and ret!uesting a revised copy; be sent in the nu.n or asking for r. one at the time EJf my next appointment. ' Date Name Of Patient or Personal Representative, " >. '.