Clinic Patient Registration Form

Maximum Health Chiropractic
New Patient Paperwork

This paperwork takes approximately 15 minutes.

Information cannot be saved, so you will need to finish once you begin.

Legal Name *

First Name Last Name
Prefers to be called:
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number: *

Area Code Phone Number
E-mail
Gender *

Male Female
If female, are you currently pregnant or is there any possibility that you could be pregnant? *

Yes No I don't know
Date of Birth *

Month Day Year
Is patient 18 or older? *

Yes No
If patient is under the age of 18, he/she is considered a minor. We cannot treat a minor without a parent or legal guardian present. If parent or legal guardian is not present, the patient will be asked to reschedule.
Full Name of responsible party: *
Since the patient is a minor, please enter the full name of the party responsible party.
*

I understand that a parent or guardian is required to accompany the patient to all appointments.
Social Security Number (Patient or responsible party if minor) *
Enter all numbers with no spaces or dashes.
Drivers License Number (Patient or responsible party if minor) *
Enter all numbers with no spaces or dashes.
Marital Status *
Spouse Name *

First Name Last Name
Spouses Date of Birth *

Month Day Year
Emergency Contact *
Emergency Contact Name *

First Name Last Name
Emergency Contact Phone *

Area Code Phone Number
Emergency Contact Relationship *
How did you hear about us? *
What event did you hear about us? *
Name of Referrer *

First Name Last Name
How did you hear about us? *

10% Complete
Employment Status *
What is your employment status *
School *
Occupation *
Employer *
Work Number *

Area Code Phone Number
Have you missed work or school due to your condition? *

Yes No

40% Complete
Have you seen other healthcare providers for this condition?

Yes No
Previous Health Care Providers

List other providers you have seen for this condition; up to 3.
Previous Provider 1
Full

First Name Last Name
Phone Number

Area Code Phone Number
Date of Last Visit

Month Day Year
Date
Notes, Diagnosis, Treatments or Prognosis given by this provider:
Are there any other providers you have seen for this condition?

Yes No
Previous Provider 2
Full Name

First Name Last Name
Phone Number

Area Code Phone Number
Date of last visit

Month Day Year
Date
Notes, Diagnosis, Treatments or Prognosis given by this provider:
Are there any additional providers you have seen for this condition?

Yes No
Previous Provider 3
Full Name

First Name Last Name
Phone Number

Area Code Phone Number
Date of Last Visit

Month Day Year
Date
Notes, Diagnosis, Treatments or Prognosis given by this provider:
Have you ever received Chiropractic care? Even if for another condition. *

Yes No
Where *
Doctor's Name: *
When did you see the other Chiropractor? *
How long were you under care? *
Date of Last Visit: *
Why did you stop? *
Was there a particular health concern for which you consulted the Chiropractor? *
Did you find treatments helpful? *

70% Complete
Medications
Are you currently taking any medications (including regularly taken over the counter medications)? *

Yes No
Do you want to provide your medication list now? *

Yes No, I will bring a list to my appointment.
Please list all medications (including regularly taken over the counter); include dosages and how often you take the medication: *
Be sure to remember your medication list when you arrive for your new patient appointment. We will need the names of the medications, the dosage and how often you take it.
Do you have any medication allergies? *

Yes (please provide a list below) No, I have no medication allergies. I will bring list of medication allergies to my appointment.
What medications are you allergic to? *
Privacy Practices Notice
This notice describes how information about you may be used and disclosed and how you can get access to this information.

Please review it carefully.

Introduction

Maximum Health Clinic of Chiropracitc is committed to giving you quality care and protecting your private health information (PHI). We are also committed to treating and using PHI about you responsibly. This notice of health information practices describes the personal information we collect, and how and when we use or disclose that information. It also describes your rights as they relate to your protected health information

This notice is effective 5/18/20.

Understanding your Health Information

Each time you visit our office, a record of your visit is made. Typically, this record contains symptoms, examination and test results, diagnosis, treatment, and a plan for future care.

This information serves as a:

Basis for planning your treatment,

Means of communication among the many health professionals who contribute to your care, Legal document describing care you received,

Means by which you or a third party payer can verify that services billed were provided,

A tool in educating health professionals, A source of data for medical research,

A source of information for public health officials charged with improving the health of this state and Nation,

A source of data for our planning and marketing,

A tool with which we can assess and continually work to improve the care we render and the outcome we achieve.

Understanding what is in your record and how PHI is used helps you to ensure its accuracy, better understand who, what when, where, and why others may access your PHI, and make more informed decisions when authorizing disclosures to others.

Your health information rights

Although your health record is the physical property of Maximum Health Clinic of Chiropractic, the information belongs to you. You have the right to:

Obtain a paper copy of this notice of information practices upon request, Inspect and copy your health record as provided for by federal law (a reasonable fee may be charged to cover the cost of copying), Amend your health record as provided by federal law, Obtain an accounting of disclosures of your PHI as provided by federal law, Request communication of your PHI by alternative means or at alternative locations, Request a restriction on certain uses and disclosures of your PHI as provided for by federal law, and Revoke your authorization to use or disclose PHI except to the extent that action has already been taken.

Our responsibilities

To maintain the privacy of your PHI

To provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about you,

To abide by the terms of this notice, and

To accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

We reserve the right to change our practices and to make new provisions effective for all PHI we maintain. Should our information practices change, we will mail revised notice to the address you have supplied. Your responsibility is to notify us of address and insurance changes.

We will not use or disclose your PHI without your authorization, except as described in this notice. We will also discontinue to use or disclose your PHI after we have received a written revocation of the authorization according to the procedures included in the authorization.

Examples of Disclosures for Treatment, Payment, and Health Operations:

Treatment: We may use your PHI within our office to provide health care services to you or we may disclose your PHI to another provider if it is necessary to refer you to them for services.

Payment: We may disclose your PHI to a third party such as an insurance carrier, an HMO, a PPO, or in order to obtain payment for services provided to you.

Personal Injury: We may disclose your PHI to your attorney in order to obtain payment for services provided to you.

Operations: We may use your PHI to conduct internal quality assessment and improvement activities and for business management and general administrative activities.

Business Associates: There are some services provided in our organization through contacts with associates. Examples include physician services in the emergency department, radiology, and certain lab tests, referrals to other physicians, and other who may provide work in our office. We may need to disclose your PHI to our business associates so they may perform the job we have asked of them. We have an agreement with these associates to protect your PHI as well.

Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition.

Communication with family: Health professionals, using their best judgment, may disclose to a family member, other relative, close personal friend, or any other person you identify, PHI relevant to that person’s involvement in your care or payment related to your care.

Research: We may disclose PHI to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.

Law Enforcement: We may disclose PHI for law enforcement purposes as required by law or in response to a valid subpoena.

Workers Compensation: We may disclose PHI to the extent authorized by and to the extent necessary to comply with laws relating to workers’ compensation or other established programs by law.

Public Health: As required by law, we may disclose your PHI to public health or legal authorities charged with law relating to workers’ compensation or other programs. Your provider is required by law to report communicable diseases and certain conditions to the Center for Disease Control in Atlanta, GA. Your PHI will be protected by our office and the CDC or health center.

For more information or to report a problem

You may file a complaint with our practice’s Privacy Officer, Sarah Palon at 727-800-2036, or with the Department of Health and Human Services. There will be no retaliation for filing a complaint.

Office for Civil Rights

U.S. Dept. of Health & Human Services

200 Independence Ave. SW

Room 509 F, HHH Building

Washington, DC 20201
*

I acknowledge that I have read Maximum Health Clinic of Chiropractic -Notice of Privacy Practices Policy

Please review and acknowledge below.
OFFICE FINANCIAL POLICY

GENERAL POLICIES:

1. A $35 fee for any returned checks will be charged to the patient’s account. Full balance including returned check fee will be due immediately.
2. All patients are on a cash basis until their respective insurance coverage and deductible may be verified by our staff.
3. This office may make payment plan arrangements on an individual basis. Any such plan or arrangement will be discussed during your report of findings.
4. If you are discharged or choose to discontinue care; we will send three statements in attempt to collect any outstanding balance. We require a minimum monthly payment of twenty dollars ($20.00) to avoid collections proceedings.Once three statements have been mailed and no payment has been received, your account will be turned over to a collections agency.
5. If after all claims have been completed, we will contact you if a balance or credit remains on your account. Please allow 3 - 8 weeks for full processing of all claims.

WHEN INSURANCE IS NOT PRESENT:

1. It is customary to pay for professional services when rendered.

We ask that you pay for your first visit with cash, check,
VISA, MASTERCARD or DISCOVER. It is our policy that
payment be made at the time of each visit unless alternate
payment arrangements are made.

WHEN INSURANCE IS PRESENT:

Verification of benefits does not guarantee third party payments!

1. If you have insurance, we will gladly file your insurance claim for you. We cannot guarantee third party insurance payment, however, we will do our best to give you an estimate of what your insurance may cover.
2. Once you have been discharged from active care and placed on maintenance care, we will continue to file your insurance as a
courtesy to you. This also does not guarantee payment by any third party entity.
3. This office will resubmit a claim ONE TIME. We will not enter into any dispute with your insurance company. If coverage problems arise, you will be expected to assist directly in dealing with your insurance company, adjustor, or agent. We are not a mediator between you and your insurance company and will not enter into any dispute with the same, as your contract is between you and your insurance company.
4. If the patient is referred to another specialist or discontinues care for any reason, the bill is due and payable in full immediately, regardless of any claims submitted. If a balance remains on the patient’s account for more than 90 days, it will be turned over to a collections agency.

If you have questions concerning the Maximum Health Clinic of Chiropractic Office Financial Policy or any other matter, please speak with the receptionist or our insurance department prior to seeing the doctor. By signing below, it states that you have read and understand the Office Financial Policy and agree to abide by these terms.

*We charge $20.00 for any missed appointment that is a NO CALL, NO SHOW.

You will be billed immediately and the fee must be paid before seeing the doctor.
*

I have read and agree to the Office Financial Policy of Maximum Health Clinic of Chiropractic.
Check here if you would like a copy of this financial policy

80% Complete
INFORMED CONSENT

We want you to be informed about the care in which you may receive, including risks and benefits. This information is given so that you may be knowledgeable about your choice to consent to chiropractic care.

Risks & Benefits of Care:

I understand and am informed that in the practice of chiropractic there are some risks to treatment including, but not limited to, fractures, disc injuries, strokes, dislocations and sprains. In the majority of cases chiropractic care offers multiple benefits including the relief of neck pain, headaches and low back pain.

Alternative Treatments including risks and benefits:

Alternative treatments include, but may not be limited to, massage therapy, physical therapy, medication, or surgery. The risks involved with these alternative treatments should be discussed with practitioners within the relative field. Chiropractic care offers a non-invasive, natural treatment of vertebral misalignments.

Risks of no treatment at all:

Chiropractic treatment involves the science, philosophy and art of locating and correcting spinal misalignments and as such, is oriented toward improvement of spinal function relative to range of motion, muscular and neurological aspects. There has been no promise, implied or otherwise, of a cure for any symptom, disease or condition as a result of treatment in this clinic. I understand that the chiropractor will use his hands or a mechanical device upon my body to adjust a joint, which may cause an audible “pop” or “click.” It is my intention to rely on the doctor to exercise professional judgment during the course of any procedures, which he feels at the time to be in my best interest. Neither the practice of chiropractic nor medicine is an exact science, but relies upon information related by the patient, information gathered during examination, and the doctor’s interpretation thereof, as well as the doctor’s judgment and expertise in working with like cases.
*

I understand and have read (or had read to me) the risks listed above. I acknowledge that the doctor will be open with me about the risks of chiropractic and will be wiling to answer any questions that I have (or may have in the future). I intend for this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.
Check here if you would like a copy of our informed consent

90% Complete
Check all that apply
*There will be signature pages to be competed in office with these forms.

The patient is between 15 and 18 years of age. The patient has retained an attorney and is currently in litigation for an auto accident. The patient will need a doctor's excuse for work or school. The patient will need someone else to have access to their health records; other than a parent or legal guardian. The patient has x - rays, MRIs or other records they would like to be released to Maximum Health Clinic of Chiropractic.
Would you like to receive your clinical summary after every visit?

The clinical summary is an after-visit summary that provides you with relevant and actionable information and instructions containing your name, provider’s office contact information, date and location of visit, an updated medication list, updated vitals, reason(s) for visit, procedures and other instructions based on clinical discussions that took place during the office visit, any updates to a problem list, immunizations or medications administered during visit, summary of topics covered/considered during visit, time and location of next appointment/testing if scheduled, or a recommended appointment time if not scheduled, list of other appointments and tests that you need to schedule with contact information, and recommended patient decision aids.
*

No, I choose to decline receipt of my clinical summary after every visit. Yes, please sign me up through my email address previously provided.
Additional Information

·         I acknowledge that I have read Privacy Practices Policy and I acknowledge the right to request a copy of Maximum Health Clinic of Chiropractic’s Notice of Privacy Practices Policy. I consent to the use and disclosure of my protected health information as specified in Maximum Health Clinic of Chiropractic's Notice of Privacy Practices Policy.

·         I understand that in the event I miss an appointment I give consent to Maximum Health Clinic of Chiropractic to send me a postcard regarding that appointment. I understand that I can request in writing an alternate form of communication.

·         I understand that my records (including x-rays) are the property of Maximum Health Clinic of Chiropracitic and if at any time I request a copy of my records there will be an additional charge for copying them (including x-rays).

·         By supplying my home phone number, mobile number, email address, and any other personal contact information, I authorize my heath care provider to employ a third-party automated outreach and messaging system to use my personal information, the name of my care provider, the time and place of my scheduled appointment(s), and other limited information, for the purpose of notifying me of a pending appointment, a missed appointment, overdue wellness exam, balances due, lab results, or other communications. I also authorize my health care provider to disclose to third-parties, who may intercept these messages, limited protected health information (PHI) regarding my healthcare events.
Electronic Signature: *

First Name Last Name
Should be Empty:

Maximum Health Chiropractic

10% Complete

20% Complete

30% Complete

40% Complete

Previous Health Care Providers

Previous Provider 1

Previous Provider 2

Previous Provider 3

50% Complete

60% Complete

Nutrition

Family Health History

70% Complete

Medications

Privacy Practices Notice

Please review and acknowledge below.

80% Complete

90% Complete

Check all that apply