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Park County Chiropractic History Form

Park County Chiropractic History Form

Our  Mission is to help you to Better Health and Better Function so you can have more Possibilities

HIPAA

Compliance

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    This is private information. It will only be used to help provide appropriate health care to you.
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    We will not sell or give anyone this phone number. This is part of your private health information.
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    We will not sell your number to anyone. This is part of your private health information.
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    We will not sell your email to anyone. This is part of your private health information.
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    We will not sell this address to anyone. This is part of your private health information
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    • Afghanistan
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    • American Samoa
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    • Denmark
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    • Iceland
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    • Iran
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    • Ireland
    • Israel
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    • Malaysia
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    • Mali
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    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
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    • Morocco
    • Mozambique
    • Myanmar
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    • Namibia
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    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
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    • Turkish Republic of Northern Cyprus
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    • Paraguay
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    • Poland
    • Portugal
    • Puerto Rico
    • Qatar
    • Republic of the Congo
    • Romania
    • Russia
    • Rwanda
    • Saint Barthelemy
    • Saint Helena
    • Saint Kitts and Nevis
    • Saint Lucia
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    • Saint Vincent and the Grenadines
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    • Trinidad and Tobago
    • Tristan da Cunha
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    • Tuvalu
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    • Isle of Man
    • US Virgin Islands
    • Wallis and Futuna
    • Western Sahara
    • Yemen
    • Zambia
    • Zimbabwe
    • Other
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    • Spouse
    • Parent
    • Legal Guardian
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    Please describe what you do, not where you work.
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    Please select from the drop down list
    • Friend or Family Member
    • Local Gym
    • Medical Doctor
    • Massage or Physical Therapist
    • Website
    • Google Search
    • Facebook
    • Other Social Media
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    * recommended Park County Chiropractic to you . May we thank them for referring you?    *         

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    * recommended Park County Chiropractic to you .  May we contact them to coordinate care?           
    *

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    Select ALL that apply
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    How & When
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    • Morning
    • Afternoon
    • Evening
    • Night (after dark)
    • From the Front
    • From the Back
    • From the Left
    • From the Right
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    • The Driver
    • The Front Passenger
    • Backseat Passenger on right
    • Backseat Passenger on left
    • Not In A Vehicle
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    Please Select
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    • Yes
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    • Yes
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    • Forward (straight ahead)
    • Backward
    • To the Left
    • To the Right
    • Up or Inclined
    • Downward
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    • Yes
    • No
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    Select All that apply
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    Please Select
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    • Yes
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    • X-Rays
    • MRI
    • CT
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    You will be billed for services until we have the required information on this page
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    How & When
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    • Yes, They have filled out forms
    • Yes, They have not filled out forms
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    Select All that apply
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    Please Select
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    • Yes
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    • None
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    How much time per activity per work day do you spend:
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    You will be billed for services until we have the required information on this page
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    • Yes
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    • Sometimes
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    Select All that apply
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    Please Tell Us Where So If Needed Your Records Can Be Requested
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    Please mark the area of pain and radiation
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    0 - 10 Scale
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    Please List Your Goals
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    Prescription or OTC
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    Please be as thorough as possible
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    Please be as thorough as possible
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    • General Health
    • Athletic Performance
    • Heart Disease
    • High Blood Pressure
    • Gall Bladder
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    • Mental Health
    • Other
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    • General Health
    • Athletic Performance
    • Heart Disease
    • High Blood Pressure
    • Gall Bladder
    • Heart Burn/Gerd
    • Thyroid
    • Pain
    • Asthma
    • Diabetes
    • Mental Health
    • Other
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    • General Health
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    Liquids
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    • Less than 1
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    I eat whole foods
    I avoid processed foods
    I sleep 7-9 hour/night
    I exercise 3+/week
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    Move the foods on the right to the left if
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  • 79

    HIPAA Notification - Please Read

    Park County Chiropractic believes in protecting your private health information! In accordance with the Health Insurance Portability and Accountability act of 1996 (HIPAA), if you would like to have the full privacy policy, it is available for review.

    Treatment, Payment, Health Care Operations: You should be aware that during the course of our relationship, we could use and disclose heath information about you for treatment, payment, and healthcare operations.

    Examples of these activities are as follows:

    Treatments: We may use or disclose your health information to other health care providers providing treatment to you.
    Payment: We may use and disclose your health information to obtain payment for services we provide to you.
    Health care operations: We may use and disclose your health information in connection with our health care operations. Health care operations include clinical education, quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and employee performance, and other business operations.
    Contacting You: We may contact you by phone, text, email, or postal service for health related matters and thank you notices. Messages may be left on an answering machine, voice mail, or with a person answering your specific phone number(s).

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    HIPAA Authorization: You may specifically authorize us to use your health information for any purpose or to disclose your health information to anyone by submitting such an authorization in writing. Upon receiving an authorization in writing from you, we may use or disclose your health information in accordance with that authorization. You may revoke an authorization at any time by notifying us in writing. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those permitted by this Notice or Law.
           *     Pick a Date    

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  • 81

    Please read this entire page prior to signing it. It is important that you understand the information contained in this document.

    The Nature of the Chiropractic Adjustment

    The primary treatment used as a Doctor of Chiropractic is spinal manipulative therapy. This procedure will likely be used to treat you. It may be with the use of hands or a mechanical instrument upon your body in such a way as to move your joints. You may feel a sense of movement or release.

    As a part of the analysis, examination, and treatment, you are consenting to the following procedures:

    Analysis and Examination Procedures:

    Vital signs (Temp, BP, etc) Postural analysis test
    Palpation (feeling muscles/joints) Neurological examination
    Range of motion testing Order of blood labs
    Muscle strength testing Order of imaging 
    Orthopedic testing Urine analysis
    Body composition analysis  

    Treatments:

    Spinal Manipulative Therapy (Chiropractic Adjustment) Hot/Cold Therapy
    Ultrasound (Therapeutic) Electrical Muscle Stimulation
    Functional Dry Needle Therapy Taping/Joint Support Procedures
    Soft Tissue Manipulation/Mobilization by hand or instrument Rehabilitation/Exercise Therapies
    Nutritional, Herbal Therapeutics  

    The material risks inherent in chiropractic treatment and other treatments: As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation and therapy. These complications include but are not limited to: fractures, disc injuries dislocations, muscle strain, cervical myelopathy, costovertebral strains and separations, accidental puncture of a lung (dry needling), light bruising and burns. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. This is extremely rare. Some patients will feel some stiffness and soreness following the first few days of treatment. I will make every reasonable effort during the examination to screen for contraindications to care. However, if you have a condition that would otherwise not come to my attention, it is your responsibility to inform me.

    The probability of those risks occurring: Fractures are rare occurrences and generally result from some underlying weakness of the bone which will be checked for during the taking of your history and during examination and/or X-ray. Stroke has been the subject of tremendous disagreement. The incidences of stroke are exceedingly rare and are estimated to occur between one in one million and one in five million cervical adjustments. The other complications are also generally described as rare.

    The availability and nature of other treatment options: 

    Other treatment options for your condition may include:

    • Self-administered, over-the-counter analgesics and rest
    • Medical care and prescription drugs such as anti-inflammatory, muscle relaxants and pain-killers
    • Hospitalization
    • Surgery

    If you chose to use one of the above noted “other treatment” options, you should be aware that there are risks and benefits of such options, and you may wish to discuss these with your primary medical physician.

    The risks and dangers attendant to remaining untreated:  Remaining untreated may allow the formation of adhesions and reduce mobility and stability, which may set up a pain reaction further reducing mobility. Over time, this process may complicate treatment, making it more difficult and less effective the longer it is postponed. More extensive interventions may become required.

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    I,    * ,   have read the above explanation of the chiropractic adjustment and related treatment(s). I will discuss any questions I have with Dr. Dobelbower.
    By signing below, I state that I have weighed the risks involved in undergoing treatment and have decided it is in my best interest to undergo the treatment. Having been informed of the risk, I hereby give my consent to treatment.
           *     Pick a Date    

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  • 83
    Please upload the Front and Back of your card(s). If you cannot do that, be sure to bring all cards with you to your appointment.
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  • 84

    Heath care should be a partnership between the patient and doctor, and we are committed to building a successful doctor-patient relationship with you and your family. Your clear understanding of Park County Chiropractic's Financial Policy is important to this shared professional relationship.
    What is your responsibility?
    It is Park County Chiropractic's policy that payment for services rendered is ultimately the responsibility of the patient, whether you have third-party assistance (major medical insurance, Medicare, personal injury insurance,) with your financial obligation. All payments for services rendered are expected at the time of service unless one of the following applies:

    • We can extend a payment plan to you if doing so helps you to follow through with all the care you require.
    • This clinic does not turn away any patient due to their ability to pay. If you feel you might qualify for our financial hardship policy, notify Park County Chiropractic immediately to begin your qualification process.
    • Personal balances may not exceed $150.00 unless a pre-arranged payment plan has been implemented. For your convenience, Park County Chiropractic accepts cash, checks, and the following credit cards: Visa, MasterCard, American Express, Discover.
    • It is your responsibility to notify Park County Chiropractic of any changes to your patient information (i.e. address, name, insurance information, etc.). Not doing so might delay your reimbursement or important information from getting to you.


    Do you have?
    Major Medical Insurance: As a courtesy to you, we will bill third party payers for you. We do not accept payment, that is accept assignment, from major medical insurance policies. If your policy covers the care provided in this clinic, they will reimburse you directly per your Out-of-Network policy guidelines. If you need help understanding your policy, please let us know. We are happy to help you.

    Medicare, Healthy MT Kids, Medicaid: We do accept payment from Medicare (except some types of Medicare Part C), Medicaid as a supplement to Medicare, and Healthy MT Kids program when the care is for an active condition. Should you prefer that we do not accept payment from your program, please let us know, and you can elect to pay at the time of care, and your program will reimburse you directly. We do not accept payment from certain types of Medicare Part C payers and we do not bill them directly for your care.

    Personal Injury or Work Comp: Payment from personal injury or workers' compensation is evaluated on case by case bases. You must present us with a claim number, adjustor, and insurance company before treatment begins, or you will be asked to pay for services until this information is received and confirmed by Park County Chiropractic. If you have an attorney helping you with a claim, please also provide contact information so that we can provide them with the necessary information.

    Lastly: Should payment be refused by your bank for any check written, Park County Chiropractic will charge a fee of $10.00 to offset the charges we will incur as a result of the returned check.

    Should you discontinue care for any reason, other than discharge by the doctor, all balances will become due and payable at that time. If you are on a predetermined payment plan, that plan will continue to be in effect until your balance is zero.

    I understand the above information and agree to follow pay for services rendered to me.       *        Pick a Date *   

    Only Read and Sign if you have: Medicare, Healthy Montana Kids, Workers' Comp, or Personal Injury Insurance.
    I authorize and direct payment be made to: Park County Chiropractic 1201 US Hwy 10 W Ste A1 Livingston, MT 59047
    For any and all benefits or reimbursement for services rendered by Dr Dobelbower, or his assistants, which amounts would otherwise be payable to me under any insurance or pre-paid health care plan. I understand I am responsible for payment of all deductible and/or co-payments and non-covered services at the time services are rendered.
    By signing, I agree to the above information.        Pick a Date    

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  • 85

    Rescheduling Policy
    Our goal is to provide quality individualized health care in a timely manner. Not showing up or late rescheduling inconveniences other people (who might be in pain) needing access to health care in a timely manner. We ask YOU to be respectful of the health care needs of other people and promptly call if you are unable to keep an appointment. If it is necessary to reschedule your appointment, we require AT LEAST 24 HOURS NOTICE. WE RESERVE THE RIGHT TO CHARGE $30 FOR MISSED APPOINTMENTS WITH LESS THAN 24 HOURS NOTICE.

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  • 86

    Patient Consent: By signing below, you are stating the information you have filled in this form is true and correct to be best of your ability. You understand your privacy rights, your payment responsibility, and Park County Chiropractic's Rescheduling policy. You will have the opportunity to ask questions and address concerns with the treating doctor prior to treatment. We look forward to meeting you!
    *     *     *     Pick a Date    

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