Adult New Patient

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Rows	Complaint	Rate your complaint
Primary
Secondary
Tertiary

Have you been treated elsewhere for this condition?

ChiropractorMDPhysical TheripistMassageOther
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Medical Professional Name

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Medical Professional Address

Street Address

Street Address Line 2

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Postal / Zip Code
Date

MonthDayYear
What was the diagnosis?
Outcome

ResolvedImprovedNo changeWorsened

Your Goals
At our office, we concern ourselves with YOUR health and YOUR wellness goals. Please list your goals for your health and wellness.
Physical Goals
Nutritional/Biochemical Goals
Psychological Goals
Method of payment for first visit*

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I consent to a professional and complete chiropractic examination and to any radiographic examination that the doctor deems necessary. I understand that ant fee for service rendered is due at the time of service and cannot be deferred to a later date. I authorize the doctor to share relevant health information with my physician.
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Relationship to patient (if not self)
As you may be aware, certain insurance companies are denying payment or reducing payment for certain medical and chiropractic services, and/or procedures. They claim these procedures are medically unnecessary, and/or the required paperwork has not been submitted properly, and/or the fees are above usual, reasonable, or customary. Please allow this to serve as a gentle reminder that you are responsible for payment for services rendered in our office, despite what your insurance company says or does. This includes bringing any payment received personally from your insurance company to our office to be placed on your account. If your insurance carrier requires preauthorization or precertification from our office, it is at the practice’s discretion whether or not to accept this administrative request. A $20 administrative fee per instance for paperwork will be due at the time of request and is generally not covered by insurance, however each carrier is different. This fee is for administrative time and is independent of third party decision. I acknowledge that I have been informed that I am financially responsible for payment on all services rendered at Action Wellness, and I give my consent for treatment, even if my insurance company/provider refuses to pay for any reason.
We accept assignment from Blue Cross Blue Shield PPO (not Blue Choice, HMO or specialty plans) and Medicare (not Medicare replacement policies). As a courtesy we will attempt to bill other carriers, however it is the practice’s discretion to accept or decline assignment. What does this mean? Depending on our experience with a carrier and how their policies evolve we may accept assignment (they send us any contribution towards your care) or not (they send you their contribution towards your care) and you will settle any and all fees with us directly at the time of billing.
Our office believes that it is important to have a certified radiologist read our x-rays to confirm our findings. We have negotiated a $35 fee for all x-ray reports that we send to our radiologist. If you have x-rays taken today in our office, this fee will be due immediately and is not billable to insurance.
By signing below I am also acknowledging that I have been given the opportunity to read and ask any questions about the HIPAA Notice of Privacy Practices as well as the Office Policy regarding the use of email/ phone and text.
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Initials*
Date*

MonthDayYear
INFORMED CONSENT TO CHIROPRACTIC CARE
Please discuss any questions or concerns with the Doctor before signing this consent.

I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic x-rays, on me (or on the patient named below, for whom I am legally responsible) by the doctors and support staff of Action Wellness.

I understand that chiropractic treatment is a procedure that involves movement of the joints and soft tissue, additionally, physical therapy and exercise may also be prescribed.

I have had the opportunity to discuss with the doctor and/or with other clinic personnel the purpose and benefits of chiropractic adjustments and other treatments outlined below. Alternatives to chiropractic care, which include rest, exercise, over-the-counter medications, medical treatment (drugs/therapy/surgery), as well as non-treatment, have been reviewed. The disadvantages to these approaches have been explained to me.

Although chiropractic adjustments are considered to be one of the safest, most effective forms of therapy for musculoskeletal problems, I understand and I am informed that there are some risks to treatments. Risks include, but are not limited to, additional soreness, dizziness, fractures, nerve tissue damage, disc injuries, strokes, dislocations, sprains/ strains, and skin irritation/burn. The probability of serious complications has been estimated at less than one in a million.

The risks associated with remaining untreated have been explained to me. These may include, but are not limited to, decreased mobility, increased pain symptoms, scar tissue adhesion formation, possible nerve damage, increased inflammation and degenerative changes. It is probable that delaying treatment will complicate future care.

In the interest of better serving our patients, we send all X-Rays to a licensed radiologist for review. We have negotiated a special rate of $35.00 for this service, which is a significant savings over standard fees. Because this service is not covered by insurance, this fee will be added to your account.

I understand that chiropractic is not an exact science and that, therefore, reputable practitioners cannot fully guarantee results. Consequently, periodic re-evaluations (approximately every 12 visits) are performed to determine progress and document medical necessity for continued care. I acknowledge that no guarantee or assurance has been made by anyone regarding the chiropractic treatment that I have requested and authorized. I have had the opportunity to read this form and ask questions. My questions have been answered to my satisfaction. I consent to the proposed treatment.

I understand that my treatment will consist of chiropractic adjustments, decompression, cold laser, rehab, and/or physical therapy.
Cosult
Chief Complaint:
Onset:
Frequency:
PMH (Past Med Hx)-Traumas, Work:
Tx/Care Sought:
Obv 1 : Yes No
Subjective reports when the problem is at its worst
VAS
Current vs future status, how we KNOW we made progress:

Goal 1:

Goal 2:

Goal 2:
SP: B W S

Obv 2: Yes No

PE1 Date

PE2 Date

PE3 Date

PE4 Date
Service Fee

New Patient Exams

NP1	99201	NP Exam, Mimimal	$40
NP2	99202	NP Exam, Extended	$100
NP3	99203	NP Exam, Detailed	$140
NP4	99204	NP Exam, Comprehensive	$210
NP5	99205	NP Exam, Complex	$260

X-Rays

XC2	72040	X-ray Cervical 2-3 views	$80
XC4	72050	X-ray Cervical 4-5 views	$125
XC7	72052	X-ray Cervical 6+ views	$175
XT2	72070	X-ray Thoracic 2 views	$80
XT3	72072	X-ray Thoracic 3 views	$120
XT4	72074	X-ray Thoracic 4 views	$160
XL2	72100	X-ray Lumbosacral 2-3 views	$80
XL4	72110	X-ray Lumbosacral 4-5 views	$160
XL6	72114	X-ray Lumbosacral 6+ views	$200
XLB2	72120	X-ray Lumbar Bending 2 view	$85
XP	72140	Pelivs 1-2 View	$80
XP3	72190	X-ray Pelvis 3+ Views	$120
XRR	RADRE	Radiology Report	$35
GCE		Gift Card Exam
GCXR		Gift Card X-ray

Exams Established Patient

E1	99211	Examination, Problem	$40
E2	99212	Examination, Focused	$60
E3	99213	Examination, Expanded	$85
E4	99214	Examination, Detailed	$125
E5	99215	Examination, Comprehensive	$200

Treatment Established Patient

A1	98940	CMT; 1-2 Regions	$50
A3	98941	CMT; 3-4 Regions	$55
A5	98942	CMT; 5 Regions	$65
AX	98943	CMT; Extraspinal	$30
M3	98940 GA	Medicare Supp CMT 3-4 Regions	$55
MA1	98940 AT	Medicare ACTIVE CMT 1-2 Regions	$50
MA3	98941 AT	Medicare ACTIVE CMT 3-4 Regions	$55
NCOV	NCOV	No Charge Office Visit	$0
SC	S8990	Supportive Care	$55

Procedures & Modalities

L1		Laser Treatment	$40
LP		Laser Promo	$20
LPKG		Laser PKG10/$350	$350
V		Vitamins
S	97014	Electrical Stimulation	$20
T	97012	Traction, Interseg., Mechanical	$20

Day 1 Payment in full

25% of Dx costs, 4 weekly pmts

Weekly Auto Debit

Should be Empty:

Rows	No effect	Painful (can do)	Painful (limits)	Unable to perform
Sitting to Stand
Climbing stairs
Driving
Computer use
Household Chores
Lifting Children
Getting down on ground and back up
Bathing
Dressing
Shaving
Sexual Activity
Sleep
Concentrate
Static sitting
Static standing
Yard Work
Walking
Running
Sweep/Vacuum/Shovel
Do dishes
Laundry
Shopping
Take Garbage out
Pet Care

Rows	Activity	Current Level	Usual Level	Desired Level
1.
2.
3.
4.

Rows	Never	1x	2x	3x	4x	5+
Exercise?
Tobacco use?
Alcohol use?
Coffee use?
Supplementation?
Pain relievers?
Soft drinks?
Water intake?
Prescription drugs?
Recreational drugs?
Vaccinations?
Metal filling in teeth?

Adult Heath Record

Personal Information

Please mark your discomfort

Your Health Profile

General History

Activities of Daily Living

Social History

Your Goals

INFORMED CONSENT TO CHIROPRACTIC CARE

Cosult

Service Fee

PE1	Date

PE2	Date

PE3	Date

PE4	Date