AllCure New Patient Paperwork

Patient Intake
Name*

First NameLast Name
Social Security Number*
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Marital Status*

SingleMarriedDivorcedWidowed
Occupation:*
Primary Care Physician Name: (if not applicable, put N/A)*
Sex/Gender*

MaleFemale

Insurance Information
Primary Insurance Co. Name:*
Primary Insurance ID#:*
Primary Insurance Group#:*
Subscriber Name:*
Subscriber D.O.B:*
Relation to Subscriber:*
Secondary Insurance Company Name: (if N/A please write N/A)*
Secondary Insurance ID#: (if N/A please write N/A)*
Secondary Insurance Group#: (if N/A please write N/A)*
Subscriber Name: (for Secondary; if N/A please write N/A)*
Subscriber D.O.B: (for Secondary; if N/A please write N/A)*
Relation to Subscriber: (for Secondary; if N/A please write N/A)*
Emergency Contact Name:*
Emergency Contact Phone #:*
Please enter a valid phone number.
How were you referred to AllCure?*

Newspaper/MagazineFamily/FriendInternetPhysicianOther
ASSIGNMENT OF BENEFITS

Patient Name: First Name* Last Name*

I irrevocably assign to ALLCURE SPINE AND SPORTS MEDICINE all my rights and benefits under any insurance contracts for payment for services rendered to me by ALLCURE SPINE AND SPORTS MEDICINE. I irrevocably authorize all my information regarding my benefits under any insurance policy relating to any claims by ALLCURE SPORTS SPINE AND SPORTS MEDICINE to be released to ALLCURE SPINE AND SPORTS MEDICINE. I irrevocably authorize ALLCURE SPINE AND SPORTS MEDICINE to file insurance claims on

behalf for services rendered to me. I irrevocably direct that all such payments go directly to ALLCURE SPINE AND SPORTS MEDICINE. I irrevocably authorize ALLCURE SPINE AND SPORTS MEDICINE to act on my behalf and report any suspected violation of proper

claims practices to the proper regulatory authorities. This assignment of benefits has been explained to my full satisfaction, and I understand its nature and effect.
Signature for Assignment of Benefits:*

Clear
Date for Assignment of Benefits:*

MonthDayYear
Date

Informed Consent to Treatment

For Physical Therapy, Occupational Therapy, and/or Chiropractic
Medical doctors, Chiropractic doctors, Osteopaths, Occupational Therapists and Physical Therapists that perform manipulation are required to obtain your informed consent before starting treatment.

I, Full Name* do hereby give my consent to the performance of conservative noninvasive treatment to the joints and soft tissues. I understand that the procedures may consist of manipulations/adjustments involving movement of the joints and soft tissues. Physical therapy, traction, ultrasound, hot packs, Tens unit, exercises, and other

therapeutic modalities may also be used. Although spinal manipulation/ adjustment is considered to be one of the safest, most effective forms of therapy for musculoskeletal problems, I am aware that there are possible risks and complications associated with these procedures as follows:

Soreness: I am aware that, like exercise, it is common to experience muscle soreness in the first few treatments.

Fractures/ Joint injury: I further understand that an isolated cases underlying physical deformities or pathologies like weak bones from osteoporosis may render the patient susceptible to injury. When osteoporosis, degenerative disc, or other abnormality is detected, this office will proceed with extra caution.

Stroke: Although strokes happen with some frequency in our world, stroke from chiropractic adjustments are rare. I am aware that nerve or brain damage including stroke to reported to occur once in one million to once in ten million treatments.

Therapy Burns: Some of the therapies used in this office generate heat and may rarely cause a burn. Despite precautions, if a burn is obtained, there will be a temporary increase of pain and possible blistering. This should be reported to the doctor. Tests have been performed on me to minimize the risk of complications from treatment, and I

freely assume these risks.

Treatment Results

I also understand that there are beneficial effects associated with these treatment procedures including decreased pain, improved mobility and function, and reduced muscle spasm. However, I appreciate there is no certainty that I will achieve these benefits. I agree to the performance of these procedures by my doctor and such other persons of the doctor’s choosing.

ALTERNATIVE TREATMENTS AVAILABLE

Reasonable alternatives to these procedures have been explained to me including rest, home applications of therapy, prescription or over-the-counter medications, exercise and possible surgery.

Consent to evaluate and treatment of a minor child: (if applicable)

I, Parent/Guardian name being the parent or legal guardian of Patient First Name Patient Last Name have read and fully understand the above Informed Consent and hereby grant permission for my child to receive chiropractic care and/or physical therapy.

I have read or have had read to me the above explanation of chiropractic treatment. Any questions I had regarding these procedures have been answered to my satisfaction PRIOR TO MY SIGNING THIS CONSENT FORM. I have made my decision voluntarily and freely.

To attest to my consent to these procedures, I hereby affix my signature to this authorization for treatment.
Signature for Informed Consent*

Clear

Informed Consent to Treatment

For Acupuncture
I First Name* Last Name* , consent to Acupuncture and other procedures associated with Traditional Chinese Medicine by a Licensed Acupuncturist. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui Na (Chinese Massage), Chinese Herbal Medicine, and nutritional counseling.

I have been informed that acupuncture is a safe method of treatment, but it may have side effects, including slight bleeding, bruising, and numbness or tingling near needling sites that may last a few days, and dizziness or fainting. Bruising is a common side effect of cupping. Burns and/or scarring are a potential side effect of moxibustion. I understand that while this document describes major risks of treatment, other side effects and risks may occur.

The herbs and nutritional supplements (which are in form of plant, animal, and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue.

I understand that herbs need to be prepared and the tea consumed according to the instructions provided orally and in writing. The herbs may have unpleasant smell or taste. I will immediately notify the acupuncturist of unanticipated or unpleasant side effects associated with the consumption of herbal teas. I will notify the Clinic Staff member who is caring for me if I am pregnant or thinking of becoming pregnant.

I understand that there is no guarantee concerning the effect of treatment provided to me and that I am free to discontinue treatment at any time. By voluntarily signing below, I show that I have read and understood this consent of treatment about the risks and benefits of acupuncture and other procedures and have the opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition and any future condition.
Print Patient Name*

First NameLast Name
Signature of Patient*

Clear
Date*

MonthDayYear
Date
Parent/Guardian Signature (if under 18)

Clear

Financial Responsibility
Thank you for choosing AllCure Spine and Sports Medicine as your health care provider. We are committed to providing excellent care to all of our patients and we always do our best to achieve this goal.

AllCure Spine and Sports Medicine is a private professional entity that is not contracted with any insurance plans other than Medicare. Even though we do not participate in your insurance plan's provider network, we pledge to help you understand and manage the financial aspects associated with providing you the very best care and attention you deserve.

Most insurance plans allow patients to select their own treating physician even if the physician they prefer is not in their insurance plan's network. To help you understand your responsibilities, we will inquire as to your plan's out-of-network benefits, and explain what, and if any financial obligations you will have for our services.

Our independence is a hallmark trait of our practice. As an out-of-network provider, the course of treatment we will provide will not be limited to what an insurance plan representative will approve, but will instead be solely upon the state of the art care that your board certified physician recommends.

All charges will be submitted to your insurance carrier on behalf as an out-of-network provider. You may be responsible for your deductible and co-insurance on allowed payments up to your out-of-pocket maximum according to your out-of-network insurance policy. Most insurance plans allow reasonable and customary payment for our services in which case you will not receive any bills. In few cases however, a particular plan may not provide reasonable and customary payment in which case you may be responsible for some of the difference between what is billed and what your insurance plan allows for payment.

In addition, your insurance company may send payment for our services directly to you. You agree to relinquish all payments that you receive from your insurance company for our services to AllCure Spine and Sports Medicine. Failure to do so will result in legal action.

By signing below, you attest that you completely understand and agree with all our financial policy as described above for the services provided by AllCure Spine and Sports Medicine and its professionals.
Name*

First NameLast Name
Signature for Financial Policy Agreement*

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Today's Date*

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Medical History Form

Patient Intake

Insurance Information

Informed Consent to Treatment

Informed Consent to Treatment

Financial Responsibility

HIPAA Authorization

Notice of Privacy Policies

Pain Diagram