HBOT New Patient Form

Health History

Hyperbaric Oxygen Therapy
Thank you for your interest in Hyperbaric Oxygen Therapy (HBOT)! We're thrilled to introduce you to this incredible healing treatment. To get started, please complete our HIPAA compliant intake form so that we can get to know you better and design the best plan for your needs. Please note that a HIPAA form cannot be saved, will time out due to inactivity, and the results cannot be accessed unless it is submitted. Therefore, we kindly request that you complete the form all at once to prevent any loss of information.

Once you've submitted the form, please call our office to book your appointment if you have not done so already. During this appointment, our Certified Functional Medicine Hyperbaric Clinician will recommend the ideal treatment package for you. You'll then experience a rejuvenating 1-hour HBOT session. Following your session, you'll have the option to pay the remaining balance for a single appointment or explore our package options.

If you have any questions, please don't hesitate to contact our office at (602) 864-0304 or email us at backoffice@darrellkilcupdc.com. We're here to assist you every step of the way on your journey to wellness!
Full Name*

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ex: 'Bill' instead of William
Birth Date*

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Gender*

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Current Address*

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Phone Number*

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Emergency Contact:*

How did you find our office?*

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What did you search to find us?*
If you can't remember exactly what you searched, please guess!
Who was it? We would love to thank them.*
Name, address, & phone number of referring physician:*
Have you ever had HBOT before?*

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Can you share details about your previous HBOT experience?*
Include the date, number of treatments, location, and pressure used.

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Disclosures and Authorizations

Please Agree to Proceed
Accuracy of Information*

I certify that the above medical information is correct to my knowledge.
Privacy and Sharing of Information H.I.P.A.A*

I authorize the clinic and its associated health professionals to collect my personal and medical information as documented above. In addition, I authorize the clinic and its associated health professionals to communicate with my family doctor and/or referring doctor as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.
Cancellation policy*

I am aware of the Cancellation Policy and give authorization to charge my credit card. Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in the office's day that could have been filled by another patient. As such, we require 24 hour’s notice for any cancellations or changes to your appointment. Patients who provide less than 24 hour’s notice, or miss their appointment are subject to a cancellation fee of $150. Patient credit card information is kept secure and on file to cover treatment cost and cancellation fee.
Refund policy*

I understand that to request a refund, I must either call the office or send an email. It's important to note that refunds can only be issued to the original card used for the purchase. Please be patient as it may take 7-10 business days for the refund to be credited to your card. Refunds are not available after your visit. If you wish to receive a 75% refund for any unused appointments, you must request it within 30 days of the purchase date. If it's been between 30 and 90 days since the purchase, you may be eligible for a 50% refund. However, no refunds will be provided after 90 days from the date of purchase. For automatic payments, once they have been processed, they are non-refundable. To avoid being charged, you must cancel before the renewal date.
Insurance Reimbursement*

I am aware that insurance reimbursement for Hyperbaric Oxygen Therapy is unlikely to be provided by my insurance, Medicare or Medicaid and assume all cost associated with treatment and maintain the responsibility of paying for treatment prior to or at the completion of every session. Hyperbaric Oxygen Therapy in the outpatient setting, such as the treatments provided in our clinic, are generally not covered by insurance due to no applicable CPT code. Our clinic will provide invoices and information that may be requested if seeking insurance reimbursement, however since there is no applicable CPT code for our outpatient Hyperbaric Oxygen Therapy, most insurance claims will be denied.
Red Light Therapy*

Safety Notice: The statements of this establishment have not been evaluated by the FDA. The information provided is not intended to diagnose, treat, cure, or prevent any disease and should not be construed as medical advice. Our products/services are low-risk, general wellness / fitness products that do not require FDA clearance, in accordance with the “General Wellness: Policy on Low-Risk Devices”. Looking directly into the bulbs of the device can lead to adverse effects. Our office advises that you advert eyes, close eyes, and/or wear the optional eye coverings in order to avoid this. We are not responsible for or injury or noncompliance. By signing this form, you acknowledge the following: I understand that if I sign up for the subscription, I will be billed every month on the same day I signed up. Example, signing up on May 15th will result in being charged on the 15th of the month, every month, until cancelation. The subscription is nonrefundable after the charge has gone through. A subscription can be cancelled only by contacting our office. I have read the disclosure, understand all risks, and give my consent to be treated.
Consent to Treat Minor

I hereby authorize the use of Hyperbaric Oxygen Therapy for my child.
Patients Have the Right To

Not to be discriminated against based on race, national origin, religion, gender, sexual orientation, age, disability, marital status, or diagnosis; Receive treatment that supports and respects the patient’s individuality, choices, strengths, and abilities; Receive privacy in treatment and care for personal needs; Review, upon written request, the patient’s own medical record according to A.R.S. §§ 12-2293, 12-2294, and 12-2294.01; Receive a referral to another health care institution if this facility is not authorized or not able to provide physical health services or behavioral health services needed by the patient; Participate or have the patient’s representative participate in the development of, or decisions concerning treatment; Participate or refuse to participate in research or experimental treatment; Receive assistance from a family member, the patient’s representative, or other individual in understanding, protecting, or exercising the patient’s rights; Be treated with dignity, respect, and consideration; Not be subjected to abuse, neglect, exploitation, coercion, manipulation, sexual abuse, sexual assault or except as allowed in R910-1012(B), restraint or seclusion; Not be subjected to retaliation for submitting a complaint to the Department or another entity; Not be subjected to misappropriation of personal and private property by any clinic personnel member, employee, volunteer, or student; Consent to or refuse treatment, except in an emergency and to refuse or withdraw consent for treatment before treatment is initiated; Be informed of alternatives to medications or surgical procedure and associated risks and possible complications of medications or surgical procedure, except in an emergency; Be informed of the clinic’s policy on health care directives, and the patient complaint process; Consent to photographs before a patient is photographed, except that a patient may be photographed for identification and administrative purposes; Provide written consent to the release of information in the patient’s medical records or financial records, except as otherwise permitted by law.

Patients Have the Responsibility To:

Be honest about matters that relate to you as a patient. Provide staff with accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters pertaining to your health. Report any perceived risks in your care. Report any unexpected changes in your condition to those responsible for your care and welfare. Follow the care, service, or treatment plan developed. Ask any questions when you do not understand or have concerns about your plan of care. Understand the consequences of the treatment alternatives and not following your plan of care. Know the staff who are caring for you. Be considerate and respectful of the rights of both fellow patients and staff. Honor the confidentiality and privacy of other patients. Be considerate of the property of North Glenn Chiropractics. Assure the financial obligations of your healthcare are fulfilled as promptly as possible.

Patients or patient’s representatives that have any concerns about patient rights, safety, or complaints or grievances, please contact the Office Manager for that clinic or call 602-864-0304 and ask to speak with the Office Manager. Written correspondence will be forwarded to the Office Manager for the patient. Any patient or patient’s representative may submit a grievance without retaliation.

Patients also have the right to contact the Department of Health at any time at:

Arizona Department of Health Services Attn: Licensing Medical Facilities 150 N. 18th Ave., Suite 450 Phoenix, Arizona 85007 (602) 364-3030 – or – www.medicare.gov/ombudsman/resources.asp

Per A.R.S. § 36-436.01(C) – The Practice’s schedule of rates is available for review upon request. Per A.R.S. § 36-425(D), State inspection records are maintained in our office. Requests may be made by calling 623-930-0887 and asking to speak with the Program Manager for Clinical Compliance.
Hyperbaric Oxygen Therapy Informed Consent

I hereby authorize Dr. Darrell Kilcup's Office and its staff, to treat me with hyperbaric oxygen therapy as prescribed in a monoplace or multiplace hyperbaric chamber. The nature and purpose of hyperbaric medicine has been explained to me and I hereby acknowledge that I understand the nature and purpose of these treatments. Additionally, I acknowledge the possible risks and side effects of hyperbaric oxygen therapy, including but not limited to those listed below.
- Barotrauma or pain in the ears or sinuses: I may experience pain in the ears or sinuses. I also understand that if I am not able to equalize my ears or sinuses that pressurization will be slowed or halted; and suitable remedies will be applied.
- Cerebral Air Embolism and Pneumothorax: Whenever there is a rapid change in the ambient pressure, there is a possibility of rupture of the lungs with escape of air into the arteries or into the chest cavities outside the lungs. This only occurs if the normal passage of air out of the lungs is blocked during recompression. Only slow recompressions are used in Hyperbaric Oxygen Therapy to obviate this possibility.
- Oxygen toxicity: The risk of oxygen toxicity and seizures has been explained to me and will be minimized by never exposing me to greater pressure or longer times than are known to be safe for the body and its organs.
- Risk of fire: With the use of oxygen in any form there is always a risk of fire, but strict precautions have been taken to prevent this and all applicable codes have been complied with.
- Risk of worsening of near-sightedness (Myopia): It is possible I may experience a decrease in my ability to see things far away. I understand that this is usually temporary and that in the majority of patients, vision returns to its pre-treatment level six weeks after the cessation of therapy. I understand that it is not advisable to get a new prescription for my glasses until at least eight weeks have passed after hyperbaric therapy.
- Temporary improvement in far-sightedness (Presbyopia): It is possible that I may experience an improvement in my ability to see things close or to read without reading glasses. I understand that this could be temporary and that in the majority of patients, vision returns to its pre-treatment level about six weeks after the cessation of therapy. I have been cautioned not to be fitted for new eyewear prescriptions for eight weeks after the end of my treatments.
- Maturing or Ripening of Cataracts: In individuals with cataracts, it has occasionally been demonstrated that there may be a maturing or ripening of the cataracts.
- Serous Otitis: Fluid in the ears sometimes accumulates as a result of breathing high concentrations of oxygen. This disappears after hyperbaric treatment ceases and often can be eased with decongestants.
- I am aware that the practice of medicine and surgery is not an exact science and I have been made no promises or guarantees as to the results of Hyperbaric Oxygen Therapy.

- I have been informed that smoking cigarettes, pipes, cigars, or any other form of tobacco and the chewing of tobacco products will result in the ingestion of chemicals into the body which may affect the efficacy of success of hyperbaric treatment. I understand that smoking may affect my results. Dr. Kilcup's Office recommends smoking cessation, however also understands that this may not be currently possible and does not exclude current smokers from HBOT.

- I hereby authorize Dr. Kilcup's Office and its staff to take medical photographs for the purpose of teaching or publication. I also understand that I will not be identified by name and that my anonymity will be preserved in any presentation or publication.

- I consent to the release of information and /or disclosure of any part of my medical record to any physician, hospital, accreditation, or regulatory organization responsible for monitoring or evaluation health facilities as well as any other facility of which I have been a client. All chambers are monitored while in clinic and while undergoing HBOT; I understand that I will be video monitored during treatment by clinical staff to ensure safe treatment.

- I have read and agree to the information above. I have also, read and understand the Patient Safety Requirements and the products that are not allowed into the chamber at any time. I hereby understand that I am entering into hyperbaric treatment at my own risk.

- I hereby give my authorization and consent to the performance of Hyperbaric Oxygen Therapy by the office of Dr. Darrell Kilcup.
HYPERBARIC OXYGEN THERAPY

Notice of Privacy Practices

Effective July 20th, 2023

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you will be notified at your next visit to update your signature/date.

You have the right to request that we restrict how protected health information about you is use or disclosed for treatment, payment, or health care operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) 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 protected health information about you for treatment, payment, and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

By signing this form, I understand that:
• Protected health information may be disclosed or used for treatment, payment, or health care operations.
• The practice reserves the right to change the privacy policy as allowed by law.
• The patient has the right to restrict the uses of their information but the Practice does not have to agree to the restrictions.
• The patient may revoke this Consent in writing at any time and all future disclosures will then cease.
• The Practice may condition receipt of treatment upon the execution of this Consent. The patient acknowledges that he/she has received a copy of our HIPAA practices brochure.

Our Office may phone, email, or send a text to you to confirm appointments.
Our Office may leave a message on your answering machine at home or on your cell phone.
Our Office may discuss your medical condition with any member of your family.
I acknowledge receipt of a copy of the 'Patients Have the Right to:' form, 'Hyperbaric Oxygen Therapy Informed Consent' form and the 'Notice of Privacy Practices'. I sign to show my understanding and my agreement to all three forms provided above. Signature:*

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Health History

Disclosures and Authorizations