Welcome to our Family Chiropractic Office

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1 Welcome to our Family Chiropractic Office Thank you for choosing our office for chiropractic care. We are committed to providing your family with the highest quality of corrective and wellness chiropractic care available so that you and your family can enjoy an active, healthy life. We will be working together to help you and your family reach your health and wellness goals. If you ever have any questions about your chiropractic care, please don t hesitate to ask Dr. Mix. All of your questions, even the ones you haven t even thought of yet, will be answered during your Chiropractic Report and your New Patient Orientation. We look forward to a long, healthy relationship with you and your family. (Continued on Back)

2 TERMS OF ACCEPTANCE When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is important that each patient understands both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment. Adjustment: The adjustment is the specific application of forces to facilitate the body s correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine. Health: The state of optimal physical, mental and social well being, not merely the absence of disease or infirmity. Vertebral subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body s innate ability to express its maximum health potential. We do not offer to diagnose or treat any disease or condition other than vertebral subluxations. However, if during the course of a chiropractic spinal examination we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of another health care provider who specializes in that area. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate major interference to the expression of the body s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations. I, have read and fully understand the above statements. (print name) All questions regarding the doctor s objective pertaining to my care in this office have been answered to my complete satisfaction. Therefore, I accept chiropractic care on this basis. (signature) (date) Consent to evaluate and adjust a minor child I, being the parent or legal guardian of have read and fully understand the above terms of acceptance and hereby grant permission for my child to receive chiropractic care. (Continued on Back)

3 Mix Family Chiropractic Personal and Family Health History Name Date Address City State Zip Phone: (H) (W) Date of Birth (Age ) Referred By Social Security # Occupation Employer Marital Status S M D W Spouse s Name Spouse s Date of Birth Number of Children and Ages Name Name Name Name Previous Chiropractic Care? Age Yes No Reason Age Yes No Reason Age Yes No Reason Age Yes No Reason You deserve to be healthy. Life is a miracle and so are you. When you were created, you were given all the blueprints, intelligence, tools, and systems to live an active healthy life. Unfortunately, your health can be interfered with through accidents and challenges that cause a disruption to your health expression. Through your examination and through your lifetime involvement in chiropractic care, we will work to remove these interferences to your natural health expression so that you can live the quality of life you deserve. Patient Spouse Child#1 Child#2 Child #3 Chiropractor s Circle all that Apply Comments 1. Was Your Birth Traumatic? Long Delivery? Y Y Y Y Y Difficult Delivery? Y Y Y Y Y Forceps? Y Y Y Y Y Caesarian? Y Y Y Y Y Breach/cephalic? Y Y Y Y Y Home birth? Y Y Y Y Y Mother given drugs during delivery? Y Y Y Y Y Induced Labor? Y Y Y Y Y 2. Growth and Development Did you ever once... Learn to care for your spine? Y Y Y Y Y Fall out of bed? Y Y Y Y Y Bang your head? Y Y Y Y Y Breastfeed? Y Y Y Y Y Childhood sickness? Y Y Y Y Y Have any Accidents? Y Y Y Y Y Have Surgery? Y Y Y Y Y Take Drugs? Y Y Y Y Y Fall while learning to walk? Y Y Y Y Y Bullied by your siblings? Y Y Y Y Y Child abuse Y Y Y Y Y Spanking? Y Y Y Y Y Pulled ear/chin? Y Y Y Y Y Other Y Y Y Y Y Chair pulled out when sitting? Y Y Y Y Y Fall down the stairs? Y Y Y Y Y Pulled by your arm? Y Y Y Y Y Experience other traumas? Y Y Y Y Y 3. Current Health Habits Did/do you... Smoke? Y Y Y Y Y Drink? Y Y Y Y Y (Continued on Back)

4 Patient Spouse Child#1 Child#2 Child #3 Chiropractor s Circle all that Apply Comments Diet (do you eat healthy foods?) Y Y Y Y Y Have you been in accidents? Y Y Y Y Y Drugs? (Prescriptive or Non-Prescriptive) Y Y Y Y Y Have Teeth Problems? Y Y Y Y Y Have Eye Problems? Y Y Y Y Y Have Hearing Problems? Y Y Y Y Y Exercise regularly? Y Y Y Y Y Have sleeping problems? (nightmares)? Y Y Y Y Y Have occupational stress? Y Y Y Y Y Have physical stress? Y Y Y Y Y Have mental stress? Y Y Y Y Y Have hobbies/sports injuries? Y Y Y Y Y Sleeping posture side stomach back Current Health Condition Present Complaint (be brief) Reason For Your Visit Today Major Pain or Problem started on Pains are: Sharp Dull Constant Intermittent What activities aggravate your condition/pain? What activities lessen your condition/pain? Is condition worse during certain times of the day? Is this condition interfering with work? Sleep? Routine? Other? Is this condition getting progressively worse? Other Doctors seen for this condition Any home remedies? Other symptoms: Headaches Neck Pain Sleeping Problems Back Pain Nervousness Tension Irritability Chest Pains Dizziness Face Flushed Neck Stiff Pins & Needles in Legs Pins & Needles in Arms Numbness in Fingers Numbness in Toes Shortness of Breath Fatigue Depression Light Bothers Eyes Loss of Memory Ears Ring Fever Fainting Cold Sweats Loss of Smell Loss of Taste Diarrhea Feet Cold Hands Cold Stomach Upset Constipation Loss of Balance Buzzing in Ear Have you been under drug and medical care? What medications are you taking? How Long? Have you had surgery? What? When? What side effects have you experienced from the drugs and surgery? Is there a family history of: Heart Disease Arthritis Cancer Diabetes Other Father s Side Mother s Side Upon the completion of your first visit, you will receive a Chiropractic Active Life Plan Explanation Sheet to discuss the different types of Active Life Plans that are available to you. Chiropractic Active Life Plans are designed to help get you feeling better quickly and to help you and your family be as healthy as possible. Please review the explanations of the Chiropractic Active Life Plans prior to your Chiropractic Report appointment so you can choose the level of participation that supports you in reaching all of your health goals. As a result of my chiropractic care, I would like to Please check all that apply Feel better quickly Have a healthier spine Have a healthier body by keeping my nerve system healthy Live a healthier lifestyle (Continued on Back)

5 Office Fee Schedule and Financial Policy Service Consultation No Charge Initial Visit $75 Your initial visit includes: Interview and Evaluation $45 Neuro-spinal Exam $30 Chiropractic Adjustment $35 Chiropractic Report No Charge Dynamic Exam $30 Adjustment $35 Insurance/Personal Injury Reports $50-$125 Financial Policy and Chiropractic Active Life Plans We are committed to providing you with the best chiropractic care possible in a caring environment and have established our financial policies to achieve that goal. You will be expected to pay for your chiropractic care at the time service is rendered unless you arrange an Active Life Plan in advance. Active Life Plans include Corrective Adjustment Plans (CAP), Wellness Adjustment Plans (WAP), or Family Adjustment Plans (FAP). These Active Life Plans are designed to be the most cost effective way to keep you and your family as healthy as possible. Details of these plans will be discussed with you during your Chiropractic Report. Health Insurance: If you have insurance that covers chiropractic, we will give you all of the information you need to get reimbursed quickly. This includes your diagnosis, prognosis, and copies of your records or reports. We have found it is easier for your record keeping, and ours, if we give you receipts at the end of your first visit and then every Wednesday thereafter. Just send in your claim form and your insurance company will communicate with you about your reimbursement. Remember, your agreement with your insurance company is between you and them. I have read and I understand the above policies. Patient Signature Date 5

6 Mix Family Chiropractic THIS NOTICE DESCRIBES HOW CHIROPRACTIC AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. In the course of your care as a patient at Mix Family Chiropractic, we may use or disclose personal and health related information about you in the following ways: *Your protected health information, including your clinical records, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assessment or treatment. *Your health care records as well as your billing records may be disclosed to another party, such as an insurance carrier, an HMO, a PPO, or your employer, if they are or may responsible for the payment of services provided to you. *Your name, address, phone number, and your health care records may be used to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information that may be of interest to you. You have a right to request restrictions on our use of your protected health information for treatment, payment and operations purposes. Such requests are not automatic and require the agreement of this office. Your name, address, telephone number, address and health records may be used to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information that may be of interest to you. If you are not home to receive an appointment reminder or other related information, a message may be left on 6 your answering machine or with a person in your household. You have a right to confidential communications and to request restrictions relative to such contacts. You also have the right to be contacted by alternative means or at alternative locations. We are permitted and may be required to use or disclose your health information without your authorization in these following circumstances: *If we provide health care services to you in an emergency. *If we are required by law to provide care to you and we are unable to obtain your consent after attempting to do so. *If there are substantial barriers to communicating with you, but in our professional judgement we believe that you intend for us to provide care. *If we are ordered by the courts or another appropriate agency You have a right to receive an accounting of any such disclosures made by this office. Any use or disclosure of your protected health information, other than as outlined above, will only be made upon your written authorization. If you provide an authorization for release of information you have the right to revoke that authorization at a later date. Information that we use or disclose based on this privacy notice may be subject to re-disclosure by the person to whom we provide the information and

7 may no longer be protected by the federal privacy rules. We normally provide information about your health to you in person at the time you receive chiropractic care from us. We may also mail information to you regarding your health care or about the status of your account. If you would like to receive this information at an address other than your home or, if you would like the information in a specific form please advise us in writing as to your preferences. You have the right to inspect and/or copy your health information for as long as the information remains in our files. In addition you have the right to request an amendment to your health information. Requests to inspect, copy or amend your health related information should be provided to us in writing. We are required by state and federal law to maintain the privacy of your patient file and the health protected health information therein. We are also required to provide you with this notice of our privacy practices with respect to your health information. We are further required by law to abide by the terms of this notice while it is in effect. We reserve the right to alter or amend the terms of this privacy notice. If changes are made to our privacy notice we will notify you in writing as soon as possible following the changes. Any change in our privacy notice will apply for all of your health information in our files. If you have a complaint regarding our privacy notice, our privacy practices or any aspect of our privacy activities you should direct your complaint to: Dr. Matthew Mix If you would like further information about our privacy policies and practices please contact: Dr. Michelle Mix You also have the right to lodge a complaint with the Secretary of the Department of Health and Human Services. If you choose to lodge a complaint with this office or with the Secretary your care will continue and you will not be disadvantaged by this office or our staff in any manner whatsoever. This notice is effective as of. This notice, and any alterations or amendments made hereto will expire seven years after the date upon which the record was created. My signature acknowledges that I have received a copy of this notice. Name (Printed please) Signature Date If you are a minor, or if you are being represented by another party Personal Representative Printed Personal Representative Signature Date 7

8 Mix Family Chiropractic- (HIPPA Authorizations) 1. Patient Authorization regarding chiropractic care being provided in an open adjusting environment: It is the practice of this office to provide chiropractic care in an open adjusting environment. Open adjusting involves several patients being seen in the same adjusting room at the same time. Patients are within sight of one another and some ongoing routine details of care are discussed within earshot of other patients and staff. This environment is used for ongoing care and is NOT the environment used for taking patient histories, performing examinations or presenting reports of findings. These procedures are completed in a private, confidential setting. We are requesting this authorization of you due to various interpretations under federal law with respect to what is known as an incidental disclosures of health information. It is our view that the kinds of matters related in an open adjusting environment are incidental matters, in the event you or someone else would not agree with us we are providing this disclosure. 2. Patient Authorization for appointment reminders and scheduling related matters: It is our desire for our staff to use your name, address and/or telephone number for the purpose of contacting you to remind you about scheduled appointments, re-evaluations or other appointment related issues. The use of this format is intended to make your experience with our office more efficient and productive as well as to enhance your access to quality health care and health information. If you choose not to agree to any of the above, other arrangements will be made for you. Your decision will have no adverse effect on your care from Mix Family Chiropractic or on your relationship with our staff. Your signature indicates your authorization of these activities. Name (printed) Signature Date This authorization may be revoked by you at any time. Revocation may be accomplished by advising us in writing of your desire to withdraw your authorization. Please allow a reasonable processing time for the change in our system to be completed. 8

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