INSURED INFORMATION (IF OTHER THAN PATIENT)
OFFICE POLICIES / AGREEMENTS
I have read over and understand these office policies
LEGAL ASSIGNMENT OF BENEFITS AND RELEASE OF MEDICAL AND PLAN DOCUMENTS
In considering the amount of medical expenses to be incurred, I, the undersigned, have insurance and/or employee health care benefits coverage with the above captioned, and hereby assign and convey directly to Coldwater Chiropractic & Wellness Center, PLLC all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for services rendered from such doctor and clinic. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize the doctor to release all medical information necessary to process this claim. I hereby authorize any plan administrator or fiduciary, insurer and my attorney to release to such doctor and clinic any and all plan documents, insurance policy and/or settlement information upon written request from such doctor and clinic in order to claim such medical benefits, reimbursement or any applicable remedies. I authorize the use of this signature on all my insurance and/or employee health benefits claim submissions.I hereby convey to the above-named doctor and clinic to the full extent permissible under the law and under any applicable insurance policies and/or employee health care plan any claim, chose in action or other right I may have to such insurance and/or employee health care benefits coverage under any applicable insurance policies and/or employee health care plan with respect to medical expenses incurred as a result of the medical services I received from the above-named doctor and clinic and to the extent permissible under the law to claim such medical benefits, insurance reimbursement and any applicable remedies. Further, in response to any reasonable request for cooperation, I agree to cooperate with such doctor and clinic in any attempts by such doctor and clinic to pursue such claim, chose in action or right against my insurers and/or employee health care plan, including, if necessary, bring suit with such doctor and clinic against such insurers and/or employee health care plan in my name but at such doctor and clinic's expenses.This assignment will remain in effect for seven years or until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I have read and fully understand this agreement.
I have read your authorization and legal assignment of benefits and agree to its terms. My signature authorizes you to disclose my PHI in the manner described above and acknowledges that I will receive a copy of this completed form for my own records.
Informed Consent to Chiropractic CareColdwater Chiropractic & Wellness CenterDr. Nicole L. Hatt, BS, DCDr. Austin Collar, BS, DCDena Warfield-Testa, LMTJulie Shepperd, LMT
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, nutritional counseling, supplement recommendations, massage therapy and diagnostic x-rays, on me (or on the patient named below for who I am legally responsible) by the doctor or clinician named above and/or other licensed doctors of chiropractic and clinicians 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 above.I have had an opportunity to discuss with my doctor 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 medicine, 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.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.
To be completed by the patient's representative, if necessary, e.g., if the patient is a minor or physically or otherwise legally incapacitated.
Please use the appropriate letters below to indicate the type and location of your sensations right now.
A=ACHE, N=NUMBNESS, B=BURNING
S=STABBING, P=PINS & NEEDLES, O=OTHER
Please rate the severity of your complaint by selecting one number on each line below, where 1 stands " No Pain " for and 10 stands for " Unbearable Pain "
This questionnaire will give your provider information about how your back condition affects your everyday life. Please answer every section by marking the one statement that applies to you. If two or more statements in one section apply. please mark the one statement that most closely describes your problem.
Index Score = [ Sum of all statements selected / (No. of sections with a statement selected x 5)] x 100
This questionnaire will give your provider information about how your neck condition affects your everyday life. Please answer every section by marking the one statement that applies to you. If two or more statements in one section apply, please mark the one statement that most closely describes your problem.