spinalworks.com - Entrance Application

ENTRANCE APPLICATION
We realize your time is valuable to you, so in order to lessen your time in our office please complete this set of health information forms prior to your first visit.

The PDF forms are fillable and saveable with Adobe Reader, so you should be able to fill them out directly. When you do this, please be sure to save your file from time to time to avoid accidental data loss. If you prefer to fill them out manually or have difficulties with your software, then please print these forms out and fill them in by hand.

You may email the completed forms to us at sw@SpinalWorks.com, or bring signed copies along to your first visit.

Thank you!
To the NEW PATIENT

STEP ONE:
All new patients are requested to fill out this personal health history questionnaire.

STEP TWO:
A one-on-one consultation with the doctor will be done to discuss your health problems and to determine what may be the cause.

STEP THREE:
A comprehensive examination and evaluation including those tests necessary
to determine the precise cause of your problem is given.

STEP FOUR:
The doctor will advise you if additional laboratory tests or x-rays are needed.

STEP FIVE:
You will be given a Report of Findings at which time the cause of your problem will be discussed.
It includes how our treatment works and what results can be obtained. You will also he advised concerning how our office procedures work. If you are accepted for care, treatment will begin.

STEP SIX:
Over the next few visits, treatment will continue as we explain what we are finding. After several visits we will sit down and discuss the care necessary to become as healthy as possible.

STEP SEVEN:
An estimate of the future care that is needed will be given and upon your acceptance, care will continue until the personal maximum correction of your problem has been obtained.

STEP EIGHT:
After maximum correction has been obtained, a schedule of care will be recommended to help prevent future problems and maintain good health.

ENTRANCE APPLICATION
WELCOME!... WE ARE HONORED YOU CHOSE US TO EVALUATE YOUR CONDITION.

SO WE MAY FILE YOUR INSURANCE FORMS FOR YOU, PLEASE FILL OUT THESE FORMS. IF YOU NEED ASSISTANCE PLEASE CONTACT US AT 602-298-1600. THANK YOU!
Name

First NameLast Name
Gender

MaleFemale
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number
E-mail Address
example@example.com
Birthdate

MonthDayYear
Date
Age
Marital Status

SingleMarriedSeparatedWidowedDivorced
Job Title
Work Phone
Please enter a valid phone number.
Spouse’s Name
Spouse’s Birthdate

MonthDayYear
Date
Social Security Number
Person responsible for this account
Name of person on your health insurance card
Name of their employer
City
Employer Phone
Please enter a valid phone number.
Children–Names & Ages
In case of emergency, whom should we contact?
Phone Number
Please enter a valid phone number.
Relationship:
FAMILY PHYSICIAN:
What is your primary complaint?
IS THIS WORKMAN’S COMPENSATION?
IS THIS PERSONAL INJURY?

Assignment & Release
In considering the medical expenses to be incurred, I the undersigned, have insurance and/or employee health care benefits coverage and hereby directly assign to SpinalWorks, Inc ("SpinalWorks") all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for any services rendered in conjunction with these expenses.

I authorize SpinalWorks to release any personal and medical information to any plan administrator or fiduciary, insurer or attorney as necessary to apply for and/or process reimbursement of my medical expenses incurred at SpinalWorks.

I authorize any plan administrator or fiduciary, insurer and my attorney to release to SpinalWorks any plan documents, insurance policy and/or settlement information as necessary to apply for, understand and/or process reimbursement of my medical expenses incurred at SpinalWorks.

I understand that I am and remain financially responsible for all charges regardless of any applicable insurance or benefit payments.

If so requested, I agree to cooperate with SpinalWorks in any attempts by SpinalWorks to secure reimbursement of medical expenses incurred at SpinalWorks from my plan administrator or fiduciary, insurer or attorney.

This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I have read and fully understand this agreement.
Patient Name:
Responsible Party:
(if not same as Patient Name listed above)
Signature:

Clear
Date:

MonthDayYear
Date

Our Financial policy
We are dedicated to providing the best possible care for you, and we want you to completely understand our financial policies to avoid any future misunderstandings.

Treatment Plan- It is very important to follow the schedule outlined in the prescribed treatment plan. Missed appointments and treatment gaps slow the healing process and may increase the number of treatments required. In this case, you will be responsible for the cost of the extra appointments beyond those outlined in the prescribed treatment plan.

Insurance Benefits- Benefit estimates given by your insurance company are no guarantee of payment, and your portion may be different from what we were told when we verified coverage. In this case, we will either refund you the excess or invoice you the difference. Insurance Co-Pay & Deductibles- When your insurance company specifies a co-pay or deductible; this payment is due at the time of service unless arranged otherwise with us.

Insurance Filings- As a service to you, we will file your insurance claim, if you assign the benefits to us so that your insurance company can pay us directly. We will also follow up for you, but if your insurance company does not pay the claim within a reasonable period, you are responsible for payment.

Self-pay- If you do not have insurance, or if we cannot verify your coverage, payment is due at time of service unless arranged otherwise with us.

Returned Checks- We will charge a fee of $25 for all checks returned unpaid.

Collections- if your account is ever assigned to an attorney or outside agency for collections or litigation, SpinalWorks shall be entitled to reasonable attorney's fees and the cost of collections. Missed Appointments- As a way to honor everyone's schedule, we reserve the right to charge a $25 fee for appointments missed without a one day advance notice.

Credit Payments- We gladly accept Visa and MasterCard, and offer CareCredit for treatment financing. Other credit arrangements may be possible, please ask if these are of interest.

Refunds- We will normally make full refund of any unapplied funds within .30 days of cancellation in case of an unfinished prepaid treatment program. The credit balance is calculated as the amounts paid, less the list price of any treatments received to date.

Your Agreement- I have read and understand the practice's financial policy. I agree to be bonded by its terms as indicated by my signature below. I authorize the release of any information necessary to determine liability for payment and reimbursement for any claim.

I hereby authorize the doctors at SpinalWorks to treat my condition as he deems appropriate. It is understood and agreed the amount paid to Health Works Spine & Sport, for x-rays is for the examination and interpretation of the X-ray negatives and will remain the property of the clinic, being on file where they can be seen at any time while patient at this office. The patient also agrees that he/she is responsible for any bills incurred at Health Works Spine & Sport.
Patient Signature

Clear
Date

MonthDayYear
Date
In case of treatment to a Minor, please complete the section below
Name of Minor to be Treated:
Guardian or Spouse Signature of Authorizing Care

Clear
Date

MonthDayYear
Date

Acknowledgement for Consent to Use and Disclosure of Protected Health Information
Use and Disclosure of your Protected-Health Information
Your Protected Health Information will be used by SpinalWorks and may be disclosed to ethers for the purposes of treatment obtaining payment or supporting the day-to-day health care operations of this office.

Notice of Privacy Practices
You should review the Notice of Privacy Practices for a more complete description of how your Protected Health information may be used or disclosed. it describes your rights as they concern the, limited use of health information, including your demographic information, collected from you and created or received by this office.. You may review the Notice-prior to signing this consent. You may request a copy of the Notice at the Front Desk.

Requesting a Restriction on the Use or Disclosure of Your Information
You may request a restriction on the use of disclosure of your Protected Health Information, however, we may or may not agree to restrict the use or disclosure of your Protected Health Information.
If we agree to your request, the restriction will be binding with this office. Use or disclosure of Protected information in violation of an agreed upon restriction will be violation of the federal privacy standards.

Revocation of Consent.
You may revoke this consent to the use and disclosure of your Protected Health Information. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected.

Reservation of Right to Change privacy practice.
This office reserves the right to modify the privacy practices outlined in the Notice.

Signature
I have reviewed this consent from and give my permission to this office to use and disclose my health information in accordance with it.
Name of Patient
Signature of Patient

Clear
Date

MonthDayYear
Date
Are you signing on behalf of someone else? Then please complete the following:
Name of Patient Representative
Relationship to Patient
Signature of Patient Representative

Clear
Date

MonthDayYear
Date

	YES	NO	YEAR
Prostate

PATIENT ACKNOWLEDGMENT
I hereby certify that the information provided in this Patient Information package to SpinalWorks is true and correct to the best of my knowledge. I understand that making false statements in this Patient Information package may disqualify me from insurance or other benefits, and may also be in violation of state and federal law.
Patient Name:
Patient Signature:

Clear
Date:

MonthDayYear
Date
If this Patient Information package has been completed for treatment of a Minor, then please complete the following:
Name of Guardian/Trustee:
Relationship to Patient:
Signature:

Clear
Date:

MonthDayYear
Date
Should be Empty:

	Past	Now	Dates & Explanation of Condition
Cancer
Balance Problems
Stroke
Thyroid Problems
Asthma
Heart Attack
HIV
Angina/Chest Pain
Diabetes
Gout
Broken Bones
Arthritis
Serious Depression
Other

	YES	NO	YEAR
Tonsils
Colon
Hernia
Appendix
Gall Bladder
Stomach
Heart
Kidney

	YES	NO	YEAR
Insulin
Cortisone
Thyroid Medicine
Male/Female Hormones
Blood Pressure
Tranquilizers/Sedatives
Birth Control

	Now	Past	Never
Fatigue
Fever
Chills
Night Sweats
Fainting
Nervousness
Concentration Loss
Dizzy Spells
Irritability
Depression
Memory Loss
Loss of Sleep
Headache
Apprehension
Muscle Pain
Muscle Weakness
Muscle Cramps
Joint Stiffness
Joint Tenderness
Spinal Curvature
Back Pain
Hot Joints
Joint Swelling
Stiff Neck
Soreness
Lumps
Masses
Seizures
Vertigo
Dizziness
Tremors
Loss of Sensation
Coordination Loss
Weak Grip
Paralysis
Difficulty of Speech
Tingling
Numbness
Weakness

	Now	Past	Never
Animal Dander
Latex
Food Allergies
Penicillin
Pollen
2nd Hand Smoke
Grasses
Sulfa Drugs
Dairy Products
Perfumes
Hay

ENTRANCE APPLICATION

ENTRANCE APPLICATION

Assignment & Release

Our Financial policy

Acknowledgement for Consent to Use and Disclosure of Protected Health Information

HISTORY OF ILLNESS / INJURY / PAIN

LOCATION

TIMING AND DURATION

SEVERITY

ASSOCIATED SIGNS AND SYMPTOMS

QUALITY

ADDITIONAL ASSOCIATED SIGNS AND SYMPTOMS

MODIFYING FACTORS

OTHER INFORMATION

CURRENT & PRIOR MEDICAL CONDITIONS

CURRENT & PRIOR MEDICAL CONDITIONS

For your SECONDARY COMPLAINT & LOCATION

ASSOCIATED SIGNS AND SYMPTOMS

QUALITY

For your TERTIARY COMPLAINT & LOCATION

ASSOCIATED SIGNS AND SYMPTOMS

QUALITY

ADDITIONAL ASSOCIATED SIGNS AND SYMPTOMS

For any ADDITIONAL COMPLAINT & LOCATION

ASSOCIATED SIGNS AND SYMPTOMS

QUALITY

ADDITIONAL ASSOCIATED SIGNS AND SYMPTOMS

PATIENT ACKNOWLEDGMENT

	YES	NO	YEAR
Breast
Uterus
Ovaries