drjasonwhite.com - New Patient Case History

CASE HISTORY
NAME

First NameLast Name
DATE

MonthDayYear
Date
ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
H. PHONE
Please enter a valid phone number.
W. PHONE
Please enter a valid phone number.
C. PHONE
Please enter a valid phone number.
DATE OF BIRTH

MonthDayYear
Date
AGE
EMAIL
example@example.com
SOCIAL SECURITY #
REFERRED BY
OCCUPATION
EMPLOYER
MARITAL STATUS:

SINGLEMARRIEDDIVORCEDWIDOWED
SPOUSES NAME
SPOUSES OCCUPATION
DATE OF BIRTH

MonthDayYear
Date
NUMBER OF CHILDREN & AGES
HAVE YOU EVER RECEIVED CHIROPRACTIC CARE?

YESNO
ABOUT YOUR HEALTH

The human body is designed to be healthy. Throughout life, events occur which damage your health. This case history will uncover the layers of damage, especially to your nerve system, that resulted in poor health. Following your exam, your chiropractor will outline a course of care to begin to correct these layers of damage and recover your innate health potential.

LOSS OF WELLNESS

Let’s begin at birth when you first damaged your nerve system, lost your wellness and began your journey to ill health.

TERMS OF ACCEPTANCE
When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective.

Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be used to attain it. This will prevent any confusion and disappointment.

Adjustment: An adjustment is the specific application of force to facilitate the body’s correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine.

Health: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmities (aka symptoms).

Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body’s innate ability to express it’s maximum health potential.

We do no offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal examination, we encounter a non-chiropractic or unusual finding, we will recommend that you seek the services of a health care provider who specialized in that area.

Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body’s innate wisdom. Our method is specific adjusting to correct vertebral subluxations.
I Name have read and fully understand the above statements.

All questions regarding the doctor’s objectives pertaining to my care in this office have been answered to my complete satisfaction and I accept chiropractic care on this basis.
Signature

Clear
Date

MonthDayYear
Date

Payment Policy

All Payments are due at the time of service.
PLEASE CHECK HOW YOU PREFER TO PAY:

CashCheckCredit CardPayment Plan
If a financial problem arises, please call for a consultation with your doctor. They will work out a payment plan that will accommodate you. DO NOT interrupt the consistency and intensity of your adjustments or you will lose the correction you have already achieved. This would result in lost time, money, and effort.

Return check fee is $25 in addition to original payment amount.

Payment for all charges, expenses and late fees is due upon receipt. While we will work with your insurer to help see that charges are paid by the patient's insurer to the extent of the patient's coverage, the patient acknowledges that the patient is ultimately responsible for the full account balance, irrespective of any insurance coverage or insurance dispute. Personal patient representatives agree that they, too are as equally liable as the patient. The patient agrees that, in the event the patient's account is placed with a collection agency or law firm, the patient will pay an additional amount equal to 45% of the entire account balance as a reasonable cost of collection or attorney fee, in addition to any court costs. Thanks for making payments promptly.

For any balance that remains on your account for more than 60 days, we reserve the right to charge a late fee of $25 per month, to be added to any unpaid balance. This fee compensates us for the additional time and resources expended by us in contacting you about payment, rebilling your account, and similar efforts. Any late fees charged to an overdue account will also become the patient's responsibility. We thank you for making payments promptly, we don't like late fees either.

We reserve the right to cap a maximum unpaid balance at $500.00. If payments have not been made by the patient, chiropractic care will be stopped. until an agreement is met and payment is made.
Authorization, Assignment and Release
(Initial) AUTHORIZATION TO RELEASE INFORMATION: You are authorized to release any information you deem appropriate concerning my physical condition to any insurance company, attorney or adjuster, or doctor in order to process any claim for reimbursement of charges incurred by me as a result of professional services rendered by you and I hereby release you of any consequence thereof.

(Initial) ASSIGNMENT OF PAYMENT: My attorney and/or insurance company are hereby requested to pay direct to the doctor listed below, any monies due him on account, the same to be deducted from any settlement made on my behalf. Further, I agree to pay the difference if any, between the total amount of his charges and the amount paid him by the attorney and/or insurance company. It is further understood that I, the undersigned, agree to pay the full amount of his charges, should my condition be such that it is not covered by my policy or if for any reason the insurance company and/or attorney refuses to pay my claim.

(Initial) MEDICARE ASSIGNMENT: I authorize any holder of medical or other information about me to release the Social Security Administration and Health Care Financing Administration of its' intermediaries or carriers any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits either to myself or to the party who accepts assignment below.
Acknowledgement and Understanding

I hereby acknowledge that I am receiving (or about to receive) health care services at Advanced Care Chiropractic, P.C. and that I have been advised that the doctor providing the services is willing to wait for payment for these services, provided that there continues to be a reasonable chance that payment will be made either by the insurance proceeds or out of the settlement of a liability case and as long as you are in the corrective care portion of your visits.

I understand that if it is determined either:
1. That there is no insurance company obligated to pay for the services, or if the insurance company involved refuses to Acknowledge an assignment to the doctor; or make other provisions for the protection of the interest of the doctor;
  Or
2. If a liability claim exists and my attorney refuses to agree to protect the interest of the doctor, or if I have not engaged Services of an attorney:
Then payment of services rendered by the doctor at Advanced Care Chiropractic, P.C. will be made on a current basis and my bill paid in full as soon as my liability claim is settled or the passage of three months from my last treatment, whichever occurs first.
Name*

First NameLast Name
Patient's Signature

Clear
Witness
Date

MonthDayYear
Date
Successful Spinal Correction Requires TWO Major Ingredients: TIME and REPETITION

Initial Uses Authorization Form
InitialI understand I have a right to review Advanced Care Chiropractic's Notice of Privacy Practices prior to signing this document. Advanced Care Chiropractic's Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Advanced Care Chiropractic. The Notice of Privacy Practices for Advanced Care Chiropractic is also provided upon request at the main administration desk of this practice. This Notice of Privacy Practices also describes my rights and Advanced Care Chiropractic's duties with respect to my protected health information.

Initial Advanced Care Chiropractic reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices at any time.

InitialAdvanced Care Chiropractic also uses limited protected health information for the following reasons: (You may opt out of this option) Marketing; internal boards, social media, testimonials, pictures on bulletin boards, or information unrelated to healthcare, etc.

By signing this form, you acknowledge that you were presented with a copy of our Notice of Privacy Practices. By supplying your home phone number, mobile phone number, email address, and any other personal contact information below, you are giving Advanced Care Chiropractic the authorization to use it for our newsletters and text messages to notify you of upcoming appointments/reminders/account balances/ Statements and any news/promotions from our office.
Person authorized for PHI:
(any person you would like to have access to your records including information to pay your balance)
Relation to Patient:
Mobile Number:
Please enter a valid phone number.
Email
example@example.com
Client/Personal Representative Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

	HEART DISEASE	ARTHRITIS	CANCER	DIABETES	OTHER
Fathers side
Mothers side

CASE HISTORY

1.BIRTH PROCESS

2. GROWTH AND DEVELOPMENT (BIRTH THROUGH TEEN YEARS)

3. LOSS OF WHOLE BODY HEALTH

PRIMARY REASON FOR CONSULTING OFFICE

SYMPTOMS

TERMS OF ACCEPTANCE

Payment Policy

Authorization, Assignment and Release

Initial Uses Authorization Form