Patient Form

Patient Information
Email*
Name*

First NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
Social Security Number
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Do we have your permission to send you text messages?*

YesNo
Do we have your permission to email you?*

YesNo
Do we have your permission to text or email you marketing messages which can update you on new services we may be offering or exciting developments? (You may unsubscribe at any time)*

YesNo
Sex*

MaleFemalePrefer Not to Say
Marital Status*

SingleMarriedWidowedSeparatedDivorced
Primary Care Provider*
Enter name of Physician or "None"
Employer
Occupation*
Business Address

Street Address

Street Address Line 2

CityState

Zip Code
Business Phone
Please enter a valid phone number.
Whom may we thank for referring you?
Whom may we thank for referring you?
If your referral was from another patient, family/friend, doctor, or attorney, please let us know their name so we may thank them.
Emergency Contact*
Emergency Contact Phone Number*
Please enter a valid phone number.
Emergency Contact Relationship*
Person Responsible for Account
Relationship to Patient
Primary Insurance Information
Do you have health insurance?*

YesNo, self-pay

Medication Allergies
List all known allergies to medications and the reaction type

Patient Consent Section
PATIENT CONSENT AND FINANCIAL RESPONSIBILITY
THE FOLLOWING TERMS, CONDITIONS AND POLICIES ARE IMPORTANT AND WILL GOVERN YOUR RELATIONSHIP WITH AND LEGAL OBLIGATIONS TO MULTI-CARE SPECIALISTS, S.C.

("MULTICARE") AND ITS HEALTHCARE PROVIDERS, INCLUDING ASHLEY EAVENSON D.C.; JONATHON BROOKS D.C.; MARK EAVENSON D.C.; DAVID PRIEBE M.D.; JOSH WIDEMAN D.C.; COREY VOSS P.T.; and GEOFFREY MILLER P.T.A. ("PROVIDERS"). YOU SHOULD READ THIS DOCUMENT CAREFULLY BEFORE SIGNING.

Consent to Treatment

Multi-Care and Providers are hereby authorized to provide treatment and health care services to patient.

Payment

Payment, including co-payments and deductibles if applicable, is due on each date of service for the services rendered on that date, unless other arrangements have been made in writing. Unless otherwise agreed in writing, Multi-care is entitled to receive the standard rates set forth from time to time in its published fee schedule for the services provided to patient, plus all out of pocket expenses reasonably incurred for patient's care. Multi-care is entitled to receive the reasonable value of any services provided to patient that are not specifically listed in Multi-Care's published fee schedule.
24-hour notice of appointment cancellation is required. A cancellation fee of $50.00 is payable for any missed or cancelled appointment if timely notice of cancellation has not been given. Health insurance and other health care benefit plans do not typically pay fees for late cancellations or missed appointments.
Please initial in the box regarding understanding of cancellation policy*
If payment is not made when due, Multi-Care will be entitled to recover all costs of collection incurred, including reasonable attorney fees.
Assignment of Benefits

If patient or patient's representative is entitled reimbursement or payment of amounts payable to Multicare Specialists or Providers by an insurance carrier, benefit plan or other third party payer ("Payment Sources"), Multicare Specialists is authorized to submit claims to Payment Sources on behalf of patient or patient's representative. However, except as otherwise required by law, Multicare Specialists may, in its sole discretion, elect (a) not to submit claims for all or any part of its services, (b) not to submit claims to one or more Payment Sources, and ( c) accept payment from any one or more of Payment Sources, without waiver or reduction of any right or claim to payment from patient or patient's representative or from any other source. Except to the extent otherwise allowed by law, patient (or, if applicable, patient's representative) shall remain primarily responsible for payment even if Multicare Specialists fails to submit claims to one or more potential Payment Sources or if Multicare Specialists is not paid in full by the Payment Sources to which claims are submitted.

To the fullest extent allowed by law, patient ( or, if applicable, patient's representative) hereby assigns to Multicare Specialists any and all rights to payment from any one or more of Payment Sources for healthcare services now or hereafter provided to patient by Multicare Specialists or Providers, including
(without limitation): (a) amounts payable under any private or public insurance or other benefit plan, including any group or individual accident, disability or health insurance policy or benefit plan or any automobile insurance policy; (b)compensation payable for such services under worker's compensation, occupational disease or other comparable laws; and (c) all proceeds of any claim or cause of action for personal injuries giving rise to such services.

Emergency

If patient has a medical emergency, patient ( or patient's representative, if applicable) should contact Multicare Specialists, but if unable to reach a Provider, should call 911 or go to the nearest emergency room.

Representative

If this document is signed by a representative, the representative represents and warrants that he has legal authority to do so. If patient is a minor or has been adjudicated as a disabled adult, the patient's parent (s) or guardian (s) assumes personal responsibility.
I, First Name* Last Name* have read the above financial policy and understand my financial responsibility to Multicare Specialists.
Patient Signature or Authorized Representative*
Dated

MonthDayYear
Date
If signed by a Representative, check applicable box and attach evidence of authorization:

ParentRepresentative of Deceased's EstateGuardianPower of Attorney
File Upload

Cancelof
Notice of Privacy Practice
Acknowledgment of Receipt of Notice of Privacy Practices
By signing this form, you acknowledge that you have received our “Notice of Privacy Practices” (the “Notice”). This Notice describes in detail how we might use or disclose your protected health information. The Notice also discusses your rights and our duties with respect to your protected health information. You have a right to review the Notice before signing this acknowledgment.

By signing this form, you further acknowledge that medical information collected at Multicare Specialists will be stored in a medical records system and kept securely in line with state and federal regulations.
Name of Patient or Legally Authorized Representative*

First NameMiddle NameLast NameSuffix
Relationship to Patient
Please provide signature*
Date

MonthDayYear
Date
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