campbellchiropracticwellness.com - CCI New Patient Form

CAMPBELL CHIROPRACTIC INC.

WELCOME TO OUR OFFICE
PATIENT INFORMATION
NAME
SOCIAL SECURITY #
ADDRESS

STREET ADDRESS

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CITYZIP

STATE
DATE OF BIRTH

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Date
SEX

MALEFEMALE
MARITAL STATUS:

SMDWSEP
HOME PHONE
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WORK PHONE
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CELL PHONE
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DATE OF LAST EXAM

MonthDayYear
Date
IF MINOR, PARENT NAME
EMERGENCY CONTACT
PHONE
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EMPLOYER (IF MINOR, PARENT’S EMPLOYER)
ADDRESS

STREET ADDRESS

Street Address Line 2

CITYZIP

STATE
REFERRED BY
PRIMARY CARE PHYSICIAN
PHONE
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EMAIL ADDRESS
example@example.com
SPOUSE INFORMATION
NAME
DATE OF BIRTH

MonthDayYear
Date
EMPLOYER
SOCIAL SECURITY #
EMPLOYER’S ADDRESS
PHONE
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INSURANCE INFORMATION
PRIMARY INSURANCE
INSURED
RELATIONSHIP TO INSURED
POLICY #
GROUP #
INSURANCE PHONE
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BILLING ADDRESS
IF ACCIDENTAL INJURY, CHECK HERE AND REQUEST ADDITIONAL FORMS FOR PROPER LEGAL OR INSURANCE REPORTING.

APPOINTMENT POLICY
Dr. Campbell is dedicated to providing you with the best care possible. Histreatment plan will include the number and frequency of visits that he projects will benefit you. For thisreason, it is crucial that you adhere to the plan and do not miss appointments.

We understand thatitis notreasonable to ask that you never cancel an appointment. However, if an appointmentis canceled, it should be rescheduled for the next day.

If you cancelthree appointmentsin a month, withoutrescheduling, Dr. Campbell will discontinue your care due to the inability to adhere to his treatment plan.

Please note that if you are late for your appointment, you may be asked to wait for the next patient to complete their treatment, or have your treatment time shortened. Walk-ins are welcome, but they may affect your wait time.

We require 24 hour notice for cancellation and rescheduling of appointments. Ifthe 24 hour advance is not given, you will be charged $25.

I have read and understand the Appointment Policy.
PATIENT/GUARANTOR SIGNATURE

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DATE

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Date
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OFFICE BILLING POLICIES
Your insurance policy is a contract between you and your insurance company. We will bill all covered services to your insurance company. However, you are responsible for any deductible, co payment and service or items not covered by your insurance company at the time of service. Please do not ask us to bill for these items.

We will prepare any necessary reports and formsto collect from your PRIMARY insurance company. We do not bill SECONDARY insurance companies. Any amount authorized to be paid directly to Campbell Chiropractic Corporation will be credited to your account upon receipt. However, all services rendered to you are charged directly to you and you are personally responsible for payment of these services. If you suspend or terminate your treatment, fees for professional services rendered will be immediately due and payable.

We will verify benefits of your policy with your insurance company. This information is documented in our files and will determine any deductible, co-pay, coverage of services, etc. However, if this information is given to us incorrectly, you are responsible for any additional monies owed to cover your account balance. THIS WILL BE YOUR RESPONSIBILITY, AS VERIFICATION OF COVERAGE DOES NOT NECESSARILY GUARANTEE PAYMENT FOR TREATMENT.
Please initial each item:

initial    We will bill all treatment dates of service once.
initial    If your insurance company requests additional information, we will submit it once.
initial    If treatment dates of service are not paid by your insurance company within 60 days of billing, you will be responsible for the complete amount owed for these services rendered. If payment is received for these charges from your insurance company, we will immediately reimburse to you any amounts paid by them.
initial    I understand that only my primary insurance company will be billed. Only copays, deductibles, write offs, provider discounts, etc. issued by my primary insurance company will be applied to my account.
INTEREST ON PAST DUE BALANCES

By signing this, you understand and agree, that any outstanding balance over 60 days that is due and payable by you, shall incur interest at the annual rate of 17%, compounded daily, until paid in full. You also agree to be responsible for all reasonable collection fees, attorney fees and court costs incurred in collection of your outstanding balance.
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ACCEPTANCE OF CHARGES
I understand and agree that my insurance will not be billed for the following service(s) and that payment for them is my responsibility at the time the service(s) is rendered.
- X-rays
- Ultrasound
- Laser
- Adjustment
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NUTRITIONAL INFORMED CONSENT
According to the Federal Food, Drug and Cosmetic Act, as amended, Section 201 (g) (1), the term “Drug” is defined to mean: Articles intended for use in the Diagnosis, Cure, Mitigation, Treatment or Prevention of Disease.

A Vitamin is not a Drug, NEITHER is a Mineral, Trace Element, Enzyme, Amino Acid, Herb or Homeopathic Remedy.

Although, a Vitamin, Mineral, Trace Element, Enzyme, Amino Acid, Herb or Homeopathic Remedy may have an effect on the disease process or symptoms, this does not mean that it can be misrepresented or classified as a DRUG by anyone.

Therefore, please be advised that any suggested nutritional advice or dietary advice is not intended as any primary treatment and/or therapy for any disease or particular bodily symptom.

Nutritional counseling, vitamin recommendations, nutritional advice and adjunctive schedule of nutrition is provided solely to upgrade the quality of foods in the patient’s diet, in order to supply good nutritional support to the physiological bio mechanic process of the human body.

Nutritional advice and nutritional intake may also enhance the stabilization of the eight (8) chemical components of the V.S.C. (Vertebral Subluxation Complex).

Please acknowledge by signing below that you have read the aforementioned and understand that any nutritional recommendations given to you by this office are nutritional recommendations and dietary suggestions, and are not for the treatment or cure for any disease process that you may possess.
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HIPAA Notice of Privacy Practices
PATEINT NAME

First NameLast Name
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GETACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations(TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services.

Uses and Disclosures of Protected Health Information: Your protected health information may be used and disclosed by your physician, our office staff, and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your healthcare and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that they physician has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your PHI to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose, as needed, your protected health information to contact you to remind you of your appointment.

We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required By Law, Public Health issues as required by law, Communicable Diseases: Health Oversight: Abuse or Neglect: Food and Drug Administration requirements: Legal Proceedings: Law Enforcement: Coroners, Funeral Directors, and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Worker’s Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.

Other permitted and Required Uses and Disclosures will be made only with your consent, authorization, or opportunity to object unless required by law.

You may revoke this authorization at any time, in writing, except to the extent that your physician or the physician’s practice as taken an action in reliance on the use or disclosure indicated in the authorization.

Your Rights: Following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your protected health information. This means you may ask us to not use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care of for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

Your physician is not required to agree to a restriction that you may request. If your physician believes it is in your best interest to permit use and disclosure of your PHI, your protected health information will not be restricted. You then have the right to use another healthcare professional.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively, i.e. electronically.

You have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive and accounting of certain disclosures we have made, if any, of your PHI.

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

Complaints:
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.

This notice was published and becomes effective on/or before April 14, 2003. We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number.

Signature below is only acknowledgment that you have received this Notice of Privacy Practices:
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CAMPBELL CHIROPRACTIC INC.

PATIENT INFORMATION

SPOUSE INFORMATION

INSURANCE INFORMATION

APPOINTMENT POLICY

OFFICE BILLING POLICIES

ACCEPTANCE OF CHARGES

NUTRITIONAL INFORMED CONSENT

HIPAA Notice of Privacy Practices