Patient Information Form

Current Medications: (Feel freee to bring in a list if you prefer)
Do you have any medication allergies?*

YesNoNot Sure
Review of Symptoms
Please choose all that apply from each category.
General:

Consent for disclosure of information:

Our clinic has always been very protective and respectful of your personal information. Under the HIPAA Privacy Act we have adopted additional guidelines to ensure the proper use, confidentiality and disclosure of your health information.
I give the clinic permission to leave a message on my voicemail / answering machine.
I give the clinic permission to discuss my medical condition with the individuals listed below.
List name/relationship:
Consent for Treatment
I hereby give consent to the healthcare providers of Wellspring Health Center, PLLC to render such care and treatment as might be required by my condition. Such care may include, but is not limited to consultations, examinations, digital x-rays, rehabilitative physical therapy, medical treatment, massage, wellness or maintenance care.*
HIPAA Privacy Policies
I acknowledge that I have been made aware of the clinic's privacy policies and may request a copy at any time. The policies are available in our reception area and by clicking the link below.*
Payment Policy
We will file claims with contracted and approved insurance plans as a courtesy. The clinic has the right to not accept non-contracted insurance plans at its discretion and in these cases; charges for services rendered are to be paid at the time of service, unless other arrangements have been made in advance. I understand that if I have not listed any insurance plan that I am responsible for the full amount of the visit unless other arrangements have been made in advance. Please note that affordable payment options and financial hardship plans are available if needed. I understand that I am financially responsible for all charges whether or not paid by insurance, unless other arrangements have been made in advance. Any unpaid patient balance will accrue a 1 ½% monthly billing charge after 90 days. Any collection fees, attorney fees, or returned check fees are the responsibility of the adult person(s) named on the account. *
Assignment of Insurance Benefits
I certify that I or my dependents have insurance through the insurance company information that I have provided and assign directly to Wellspring Health Center, PLLC all insurance benefits, if any, otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions. In the event that my insurance company forwards payment directly to me, instead of Wellspring Health Center, PLLC, I will immediately deliver said payment to Wellspring Health Center, PLLC. I also verify that all the information contained on the history forms is true and correct to the best of my knowledge and belief. I authorize Wellspring Health Center, PLLC to release my complete records to its business management company and/or to my insurance carrier(s) and or agents to secure payment of benefits; I also authorize Wellspring Health Center, PLLC designation of representation for insurance claims appeals.*
Release of Records
I authorize the release of my complete records to or from other physicians or medical facilities that may be pertinent and necessary to my care and treatment.*
List any exceptions to medical records to be released:
Patient (or Guardian) Name*
Today's Date*

MonthDayYear
Date
Patient or Guardian Signature*

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Should be Empty:

Patient Information

Work Injury Information

Workers Compensation Carrier

Personal Injury Claim Information

Auto Insurance Information

Auto Accident Information

Consent for disclosure of information: