New Patient Intake

ACCOUNT INFORMATION
Name*
First and Last
Nickname
Gender
Birthdate*

MonthDayYear
Date
Age*
Marital Status*
Pronouns
Address*

ADDRESS

Street Address Line 2

CITYSTATE

ZIP
Phone*
Cell Phone Carrier
Referred By
Family member seen by us
Employer
Occupation
Email Address*
example@example.com
Primary Care Physician
Location of Primary Care
Insurance*
ex. BCBS, Medica, Health Partners, etc.
Name of Insurance Subscriber (Policy Holder)
Birthdate of Subscriber

MonthDayYear
Date
Emergency Contact*
Relationship to Emergency Contact*
Phone Number of Emergency Contact*
Address of Emergency Contact
Financial Policy

Hulsebus Chiropractic will submit your chiropractic charges to your insurance policy. You are responsible for the balance not covered by your insurance company. Co-pays are due at the time of service. Please sign that you have read and understand the financial policy.
Financial Policy Signature*

Clear
Date*

MonthDayYear
Date
Name of Guardian
If patient is a minor
Guardian Signature

Clear

HIPAA Compliance
HIPAA Privacy Act

Our notice of privacy practices provides information about how we may use or disclose protected health information. The notice contains a patient's rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change. If so, you will be notified at your next visit to update your signature/date. You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthacre operations. We are not required to agrree with this restriction, but if we do, we shall honor this agreement. The HIPAA law allows for the use of the information for treatment, payment or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymouse usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that
- Protected health information may be disclosed or used for treatment, payment or healthcare operations.
- The practice reserves the right to change the privacy policy as allowed by law.
- The practice has the right to restrict the use of the information, but the practice does not have to agree to those restrictions.
- The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
- The practice may condition receipt of treament upon execution of this consent
May we phone, email or send a text to you to confirm appointments?*

YesNo
May we leave a message on your answering machine at home or cell?*

YesNo
May we discuss your medical condition with any member of your family?*

YesNo
If yes, please name the members allowed
Name*
First and Last
Date*

MonthDayYear
Date
Signature for HIPAA Policy*

Clear
Witness
Name*
First and Last
Signature of Patient or Guardian for Informed Consent*

Clear
Date*

MonthDayYear
Date
Description of Guardian's Relationship/Authority if patient is a minor
Should be Empty:

ACCOUNT INFORMATION

Current Health History

Past Health/Family History

HIPAA Compliance