omahachirosports.com - Chiro New Patient Forms

Patient Demographic Sheet
Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home #:
Please enter a valid phone number.
Cell #:
Please enter a valid phone number.
SSN:
Date of Birth:

MonthDayYear
Date
Gender:
Email:
example@example.com
Martial Status:

SingleMarriedOther
Employment Status:

EmployedFT StudentPT StudentRetiredSelf EmployedOther
Occupation:
How did you head about us? (Referred by)
Emergency Contact:
Relationship to Patient:
Telephone #:
Please enter a valid phone number.
Patient's Printed Name:
Signature:

Clear
Date:

MonthDayYear
Date
Relationship to Patient if minor:

Primary Insurance:
Insurance Carrier: Insurance #:
Member ID:
Group #:
Policy Holder:

First NameLast Name
Date of Birth:

MonthDayYear
Date
SSN:
Relationship to Patient:
Secondary Insurance:
Insurance Carrier: Insurance #:
Member ID:
Group #:
Policy Holder:

First NameLast Name
Date of Birth:

MonthDayYear
Date
SSN:
Relationship to Patient:
Acknowledgment:

I certify that the above information is true and correct to the best of my knowledge. I understand the importance of current information and know it is my responsibility to keep this office informed of any changes in my insurance or personal information. I realize any claims that are denied or delayed due to this information not being up to date are my responsibility. I understand fully that in the event my insurance company or financially responsible party does not pay for the services I receive, I will be financially responsible for payment.

By signing below, I verify the information above is correct and true.
Patient or Legal Representative's Signature:

Clear
Date:

MonthDayYear
Date

Insurance Benefits Disclosure
If you are covered by a health insurance plan, as a courtesy, the staff of BC Healthcare will check your insurance policy for the availability of benefits. Please provide your insurance information to the front office staff. While our office strives to get the most accurate quote of benefits, many insurance policies are different, therefore the quote we provide is not a guarantee of those exact benefits or payment by your insurance company. Your claim will be processed according to your plan guidelines. If your claim processes differently from the benefits we have quoted, the insurance company will side with the plan and will not honor the benefit quote we received.

It is the policy of BC Healthcare that payment is due at the time of service unless other financial arrangements are made in advance. After insurance processing, you may be billed for any outstanding balances. If there is a credit, you will be provided a refund per the explanation provided in the office financial plan.

Accepting your insurance does not place all financial responsibilities onto this practice, and you will be held accountable for any unpaid balances by your plan.

Although we are contracted with most insurance carriers, our services may not be covered by your particular insurance plan. Being referred to our clinic by another physician does not necessarily guarantee that your insurance will cover our services. Please remember that you are 100% responsible for all charges incurred: your physician's referral and our verification of your insurance benefits are not a guarantee of payment.

We highly recommend you also contact your insurance company to verify your coverage and benefits.

If a secondary insurance policy is applicable do not assume that you owe nothing and that all services will be covered completely by both insurance policies.
Patient's Printed Name:
Signature:

Clear
Date:

MonthDayYear
Date
Relationship to Patient if minor:

Office Financial Policy
Our policy is to extend to you the courtesy of allowing you to assign your insurance benefits directly to us. This policy may reduce your out-of-pocket expenses and allows you to place your family under care.

Initial   1. If You Do Not Have Insurance: All payments are expected at the time of service. Monthly installments are allowed if an authorized payment plan is set.

Initial   2. If You Have Insurance: All co-payments are expected at the time of service. All other balances may be paid in monthly installments if an authorized payment plan is set.

Our payment plans make treatment an affordable part of your family budget.

Should the patient balance go past 121 days past due, a payment plan MUST be set up for treatment to continue. This requires a credit card number to be kept on file with a minimum monthly payment of $25. An authorization agreement will be signed with all information pertaining to the payment plan defined.

You are considered a self-pay patient until you bring in a copy of your insurance card.

If your carrier has not paid a claim within sixty (60) days of submission, you agree to take an active part in the recovery of your claim.

Refunds will be issued for any amount exceeding $5.00, unless otherwise stated by the patient that they would like to keep the credit on their account to apply to future visits. If a patient becomes inactive after 12 months, we will send a refund check for the full amount.

Initial   I understand and agree that health and accident insurance policies are an arrangement between my insurance company and myself- not between my insurance company and this office. I authorize this clinic to release any medical information and to complete any usual and customary reports and forms at no charge to assist in collecting from my insurance company.

Initial   I, the patient, am responsible for paying all sums for services rendered and products delivered, and those sums become due immediately upon billing. I further agree that interest will accrue, and I will pay all principal and interest on all sums which remain unpaid after ninety (90) days at the rate of sixteen percent (16%) per annum on all open balances. Should my account need to be taken over by a Collection Agency, I agree to pay an additional fee of $100. I also agree that all communications should be made through the Collection Agency to resolve the balance.
Patient's Printed Name:
Signature:

Clear
Date:

MonthDayYear
Date
Relationship to Patient if minor:

HIPAA Compliance Patient Consent Form
HIPAA Compliance Patient Consent Form Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient's rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment, or healthcare 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 information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:
- Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
- The practice reserves the right to change the privacy policy as allowed by law.
- The practice has the right to restrict the use of the information, but the practice does not have to agree to those restrictions.
- The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
- The practice may condition receipt of treatment upon execution of this consent.
May we phone, email, or send a text to you to confirm appointments?

YESNO
May we leave a message on your answering machine at home or on your cell phone?

YESNO
May we discuss your medical condition with any member of your family?

YESNO
If YES, please name the members allowed:
Patient's Printed Name:
Signature:

Clear
Date:

MonthDayYear
Date
Relationship to Patient if minor:

INFORMED CONSENT TO CHIROPRACTIC TREATMENT
Please read this consent form and discuss it, if you would like to, with your doctor, and then sign where indicated at the bottom of the page. Clinicians who use spinal manual therapy techniques, such as joint manipulation, mobilization, or adjustment are required to inform their patients that there may be some risks associated with such treatment.

Treatments provided at this clinic, including the spinal adjustment, manipulation and/or mobilization, have been the subject of much research conducted over many years and have been demonstrated to be appropriate and effective treatments for many common forms of spinal pain, pain in the shoulder/arms/legs, for headaches and other neuromusculoskeletal symptoms. Treatment provided at this clinic may also contribute to your overall wellbeing. The risk of injury or complication from manual treatment is substantially lower than the risk associated with many standard medical treatments given for the same forms of musculoskeletal pain, such as muscle relaxing drugs, anti-inflammatory drugs such as aspirin, or pain pills. The most frequent risk that occurs in a chiropractic clinic is from burns associated with hot packs. Our office does not even use hot packs. Rarely some patients have reported muscle or ligament sprains or strains or rib fractures following an adjustment, however, our low amplitude techniques make that extremely improbable. There have been some "reports" of disc injury following an adjustment, however, there is NO scientific study that has ever demonstrated that such injuries are caused, or may be caused, by adjustments or manipulative techniques. In fact, there is much scientific evidence to the contrary. Chiropractic adjustments offer disc patients significant relief and a speedier recovery without the need to resort to surgery. There have also been "reports" of injuries to a vertebral artery following neck adjustments. Usually, these patients have a predilection for vertebral artery dissection prior to their chiropractic visit. These patients are already at risk for stroke under many positional activities. They are already at risk for serious neurological injury and impairment and are no more likely to have such an incident in a chiropractic office than they are in a medical clinic or a beauty salon. This form of complication is astronomically rare, occurring about I in 12- 50 million and has little or no correlation with the chiropractic adjustment.

Your clinician will evaluate your individual case, provide an explanation of care and a suggested treatment plan, or alternatively a referral for outside consultation and/or further medical evaluation if deemed necessary.

Initials Acknowledgement: I acknowledge that I have read, discussed, or have been given the opportunity to discuss with my clinician the nature of chiropractic treatment in general and my treatment as well as the contents of this consent.

Consent: I consent to the chiropractic treatment(s) offered or recommended to me by my clinician, including joint adjustment or manipulation or mobilization to the joints of my spine (neck and back), pelvis and extremities (shoulder, upper limbs, and lower limbs), including various modes of physical therapy, and if necessary, diagnostic x-rays. I intend this consent to apply to all my present and future treatments at this clinic.
Patient's Printed Name:
Signature:

Clear
Date:

MonthDayYear
Date
Relationship to Patient if minor:

Patient Demographic Sheet

Primary Insurance:

Secondary Insurance:

Insurance Benefits Disclosure

Office Financial Policy

HIPAA Compliance Patient Consent Form

INFORMED CONSENT TO CHIROPRACTIC TREATMENT

Patient Exam Form