Patient Intake

Patient Intake
Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Legal Sex:

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number*
Marital Status
Phone Number*

Area CodePhone Number
Email
example@example.com
Occupation and Employer
Take Photo of Your Driver's License
Emergency Contact*
Who is your Primary Care Physician?

NameFacility
Date and reason for your last doctor visit:
Are you also receiving care from any other health professionals?

YesNo
- If yes, please name them and their specialty:
How did you hear about us? *
e.g. Person's name, Google, Drive by, etc.

Billing Information

Who is responsible for your bill?
How will your visits be covered?*
Health Insurance Company Name
Take a photo of the FRONT of your Insurance Card
Take a photo of the BACK of your Insurance Card
Subscriber

Health Information

What's the reason for your visit?
Primary Complaint*
Draw where you are having complaints*
How did it start?*
When did it start?*
My pain level in the last 24 hours:*
Is this problem:*

ConstantFrequentOccasionalIntermittent
Pain is radiating to:
Pain is described as:*
Do you have any pain or difficulty completing any of the following?
Along with your primary complaint, do you also have any of the following?

General Health Information
General Medical Questionnaire
Provide details for any of the above conditions and/or list any other medical problems:

Have you had any of the following radiology studies done in the last 12 months?

	YES	When	Where
X-rays
MRI
CT scan
Ultrasound
Other

List all medication you are taking including OTC and Vitamins
List all previous Major Illnesses/Injuries and Surgeries
Do you have a Pacemaker and/or Defibrillator?*

YesNo
FEMALE PATIENTS: Are you pregnant?

Privacy Policy

HIPPA
Notice of Privacy Policy

Our Notice of Privacy Policy provides a description of the uses and disclosures we make of your health information. You have the right to read this notice before you decide to agree to this consent. You have the right to obtain a physical copy of our Notice or Privacy Policy at any time.

Right to Revoke: You have the right to revoke this consent at any time by giving us a written notice submitted to the Contact Person listed below. This revocation does not affect any action we took in reliance on this consent before we received your revocation and we may decline any further treatment if you revoke this consent.

Patient/Doctor Communication: By agreeing to this consent, you give the right for Dr. Crawford and his staff to contact you via text, email, phone call or mail regarding your treatment, account and other communication.

You may obtain a printed copy of our Notice or Privacy Practices Policy, including any revisions, and this consent at any time by contacting the Office Manager, Brittney Jackson, RN – (706) 891-1011
Consent for Use and Disclosure of Health Information

By agreeing below, you are consenting to the use and disclosure of your protected health information to carry out treatment, payment activities and healthcare operations by Dr. Crawford and his staff at Crawford Chiropractic (King Chiropractic Clinic, PC). You also give consent for any other medical records to be released to this office from any other facility upon request and/ or any other person(s) you have listed below (if applicable).
Persons allowed to discuss/receive my health information

Patient Responsibility

Who is responsible for your account?
Patient Responsibility - Health Insurance

Insurance Disclaimer: “A quote of benefits and/or authorizations does not guarantee payment or verify eligibility. Payments of benefits are subject to all terms, conditions, limitations, and exclusions of the member’s contract at time of service. “

Insurance Liability for Payment: Your health insurance company will only pay for services that it determines to be “reasonable and necessary.” If your health insurance company determines that a particular service is not reasonable and necessary, or that a particular service is not covered under the plan, your insurer will deny payment for that service. We suggest to all patients that they discuss this with our staff or your insurance to confirm that services are covered.

Under this arrangement, you are responsible for paying your co-pay, any non-covered portions, and any deductible you have yet to cover. In addition, if your insurance company does not pay for our services, you agree to pay for the services provided in our clinic.

Beneficiary Agreement: I understand that my health insurance company may deny payment for the services identified above, for the reasons stated. If my health insurance company denies payment, I agree to be personally and fully responsible for payment. I also understand that if my health insurance company does make payment for services, I will be responsible for any co-payment, deductible, or coinsurance that applies.

Patient Responsibility – No Health Insurance

We offer uninsured patients the ability to enter into an annual (per calendar year) contract with the practice and by doing so we are able to extend discounted services to the patient. All uninsured patients will be required to sign up for membership. Insured patients with a high copay/deductible may also enter into the contract for a more cost effective solution to care but upon signing up will decline the right to use their insurance or have claims sent to insurance for the current calendar year.

Patient Responsibility – Auto Accident, Worker’s Compensation, Personal Injury

We accept Auto Accident, Worker’s Compensation, and Personal Injury cases and you are required to complete a lien and must provide all insurance company or attorney information for statements to sent to. You are ultimately responsible for payment for services rendered. Worker’s Compensation cases must be pre-approved through your employer before starting treatment.

► All accounts regardless of responsibility are considered past due if no payment has been received within 30 days from receipt of invoice and are subject to a 1.5% monthly finance charge. Delinquent accounts will be sent to a collection agency after 90 days that reports to major credit bureaus after we have exhausted all attempts to collect the balance with all applicable fees added to the account balance.

Consent for Care and Treatment
You have the right, as a patient, to be informed about your condition and the recommended medical, surgical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s).

This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services.

You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test and/or service ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions.

I voluntarily request a physician, and/or mid-level provider (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice.
Signature: By typing your name below, you certify that you have read and fully understand the above statements/policies and consent fully and voluntarily to their contents and clicking "Submit", you are electronically signing this document. *

First NameLast Name
Should be Empty:

Patient Intake

Billing Information

Health Information

General Health Information

Privacy Policy

Patient Responsibility

Consent for Care and Treatment