WELCOME
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- Darren Barker
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1 WELCOME Thank you for choosing our office for your chiropractic care. We at Columbia County Chiropractic Center, LLC strive to provide excellent care to all of our patients, and so in that endeavor, we ask that you be prompt for your appointment. If you are more than 15 minutes late, we may find it necessary to reschedule your appointment, again in consideration for all of our patients. It is our goal to spend quality time with each of you. Please bring the completed forms with you to your appointment, and if you have any questions regarding the forms, please call us at We look forward to meeting you.
2 Columbia County Chiropractic Center, LLC 279 SW Main Blvd, Lake City, FL (386) Darrel T. Mathis, D.C., F.A.C.O. James R. Fraser, III, D.C. Patient Information Today s date Chart # Patient s Name Nickname Address City State Zip - Phone (hm) (wk) (cell) would you like to receive our Newsletter? -YES -NO Social Security # - - Date of Birth - - age sex Employer Occupation If student, name of school Marital Status: single married widowed divorced separated other Spouse s Name In case of emergency contact phone # Relation to you Who may we thank for referring you? Other referral sources: YP ATT Yellowbook Insurance Company Google (or) search engine Physician Brochure website Other PAYMENT IS REQUIRED AT THE TIME OF SERVICE Method of payment: cash check credit/debit card INSURANCE ASSIGNMENT AND RECORDS AUTHORIZATION I hereby authorize Columbia County Chiropractic to furnish information to insurance carriers, attorneys, or adjusters, concerning my illness and treatments, and I hereby assign to the physician(s) all payments for medical services rendered to me or my dependents. I understand that I am responsible for any amount not covered by my insurance. Signature Date Parent/Guardian signature (if patient is a minor) FOR MEDICARE PATIENTS ONLY AUTHORIZATION FOR MEDICARE BILLING PURPOSES LIFETIME FILE (Medicare Patients Only) I certify that the information given to me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me, to release to the Social Security Administration or its intermediaries or carriers, any information needed for this or any related Medicare claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for physician services, to the physician if he so desires to accept. Signature Date
3 FINANCIAL POLICY Revised 2/2/11 As your family chiropractor, we are committed to providing you with the best possible chiropractic care. In order to achieve this goal, we need your assistance and understanding of our financial policy. We will gladly discuss your proposed treatment and do our best to answer any questions relating to your insurance. However, you must realize: 1. Your insurance is a contract between you, your employer, and your insurance company. We are not a party to that contract. 2. Not all services are covered benefits in all contracts. Some insurance companies arbitrarily select certain services they will cover. We must emphasize that, as your chiropractic provider, our relationship and concern is with you and your health, not your insurance company. While filing your insurance claim is a courtesy that we extend to our patients, all charges not covered by your insurance are your responsibility from the date the services are rendered. Any balance on your account after 60 days, will be turned over for collection. Delinquent charges and costs of the collection process will be added to the outstanding balance. We realize that emergencies do arise and may affect timely payment on your account. If such extreme cases do occur, please contact us promptly for assistance in the management of your account. We accept cash, personal checks and credit/debit cards. Returned checks are subject to a $25.oo service fee. PPC/PPO/HMO Insurance coverage: Copayment must be paid at the time of service, unless prior arrangements have been made. Medicare insurance coverage: Medicare has a deductible and then pays 80% of the manipulation only; please see additional paperwork. Worker s compensation: We must have authorization from either your employer or the insurance carrier prior to your first appointment. Auto accidents: Until coverage is verified, payment is due at the time of service even if you have an attorney and/or the accident was not your fault. Once coverage has been verified, then your deductible and/or copayment will be due at the time of service. If you have any questions about the above information, please do not hesitate to ask us. We are here to help you. My signature below states that I have read and understand the guidelines of the financial policy. Patient, Parent/Guardian Signature: Date:
4 ACKNOWLEDGMENT OF NOTICE OF PRIVACY PRACTICES I acknowledge that I am provided the opportunity to review a copy of the Notice of Privacy Practices, found on our website, and that I have read it or declined the opportunity to read it, but do understand that Columbia County Chiropractic is bound by the Notice of Privacy Practices regarding my medical records. I understand that this form will be placed in my patient chart and maintained for six years. Date Patient name (please print) Patient signature Parent/Guardian (if patient is a minor) * * * If you would like a copy of the Notice of Privacy Practices for your own records,* * * please let us know at the front desk and we will provide one for you.
5 Case History Columbia County Chiropractic Center. LLC 279 S.W. Main Blvd. Lake City, FL Name Date / / Chart # Age Race Gender Height Weight *Be sure to list all conditions or symptoms, both past and present. Review of systems If you answer yes, Please explain 1. Do you have skin, hair or nail problems? NO YES Explain: 2. Do you have mouth and/or throat problems? NO YES Explain: 3. Do you have nose and/or sinus problems? NO YES Explain: 4. Do you have ear problems? NO YES Explain: 5. Do you have eye problems? NO YES Explain: 6. Do you have chest or lung (breathing) problems? NO YES Explain: 7. Do you have heart and/or blood vessel problems? NO YES Explain: 8. Do you have blood or lymph node problems? NO YES Explain: 9. Do you have digestive problems? NO YES Explain: 10. Do you have genital problems (e.g. prostate, testicular, vaginal)? NO YES Explain: 11. Do you have urinary (including kidney or bladder) problems? NO YES Explain: 12. Do you have any nervous system diseases and/or mental health problems? NO YES Explain: 13. Do you have any gland and/or hormone problems? NO YES Explain: 14. Any allergies or allergic reactions, or immunity problems? NO YES Explain: Type of allergy: medication food environmental Reaction 15. Do you have any muscle, tendon or ligament problems? NO YES Explain: 16. Do you have any bone or joint diseases (examples: bone=osteoporosis, joint= arthritis)? NO YES Explain: Females 17. Have you had menstrual problems? NO YES Explain: 18. Have you ever taken birth control pills? NO YES - For how long? 19. Is there any chance that you are currently pregnant? NO YES Explain: 20. Do you have any breast problems? NO YES Explain: Additional Questions: 21. Do you have problems with recurring headaches? NO YES Explain: 22. Are you losing weight without trying? NO YES Explain: 23. Does your pain wake you up at night? NO YES Explain: 24. Have you had a change in bowel or bladder habits? NO YES Explain: 25. Have you had a sore that doesn t heal? NO YES Explain: 26. Have you recently had any unusual bleeding or discharge? NO YES Explain: 27. Do you have a thickening/lump in the breast or elsewhere? NO YES Explain: 28. Do you have indigestion or difficulty swallowing? NO YES Explain: 29. Have you had an obvious change in a wart or mole? NO YES Explain: 30. Do you have a nagging cough or hoarseness? NO YES Explain: 31. In the space below, please explain or give additional details regarding the information you have given above. Also, if there is any information about your health history which was not requested, please fill it in below. Past History: 32. List any diseases which you have had in the past, including childhood diseases: 33. Tell us if you have ever been diagnosed as having a particular condition such as diabetes, cancer, AIDS, etc. 34. Have you suffered any physical injuries such as falls or blows, automobile accidents, whiplash, concussion or head injury, lacerations, sprains, strains, dislocations, broken or cracked bones? Please include dates. NO YES Explain: 35. List any surgeries you have had (don t forget appendix, tonsils, ear tubes, wisdom teeth, C-section etc.) Surgery Surgery Surgery Signature Date Date Date Date
6 36. Have you ever been hospitalized for any reason other than surgery (childbirth)? NO YES Explain: 37. Medications: Please list below all medications (prescription & non-prescription) that you are currently taking or take on an occasional basis: Date started Medication name Strength Dosage Frequency Prescribing doctor Date started Medication name Strength Dosage Frequency Prescribing doctor 38. Your diet is: Balanced Fair Poor Excessive Restricted Family History 39. Disease in family: (arthritis, heart disease, cancer, diabetes, multiple sclerosis, etc.) Living or deceased Father living deceased (age) Cause Mother living deceased (age) Cause Brother(s) living deceased (age) Cause Sister(s) living deceased (age) Cause Grandmother (P) living deceased (age) Cause Grandfather (P) living deceased (age) Cause Grandmother (M) living deceased (age) Cause Grandfather (M ) living deceased (age) Cause Hospitalizations/Major Illness/Injury 40. Any hospitalizations? NO YES Explain below Date Reason for Hospitalization Hospital name 41. List (recent) immunizations/vaccinations: Date Vaccine Date 42. When was your last tetanus shot: Flu shot: Social History Vaccine 43. In what position do you usually sleep? how many hours? other 44. Do you exercise on a regular basis? NO YES Explain: 45. What hobbies do you have, with your free time? 46. Do you use Caffeine? Nicotine? (Gum, dip, vapor) Recreational drugs? Alcohol? 47. How often day/week day/week day/week day/week 48. How much? cup(s) amount amount drink(s) Smoking status 49. Never smoked Current everyday (how much?) Current occasional smoker (how much, how often?) Former smoker how long did you smoke? 50. Please describe your work. Professional Physical Labor Driver Clerical Factory Homemaker student Other 51. Physical Demands: Heavy Moderate Mild Sedentary 52. How would you rate your stress levels: High Medium Low Please describe your current complaint; in other words, what brought you to see us? 53. What are your expectations for todays visit? 54. Who s your: Primary Doctor? 57. Other Specialists: 55. OB/GYN? 56. Dentist? Signature Date Columbia County Chiropractic Center. LLC
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