Patient Intake Form

*You must provide a current insurance card in order for insurance to be verifiedand/or billed.

As a courtesy, Complete Care Health Services will verify benefit coverage and billyour primary/secondary insurance. However, we will not be able to process yourinsurance claims unless all information has been provided by you, the patient. If allinformation is not provided you will be responsible for the remaining balance.

Again, we will assist you in obtaining payment from your insurance carrier, theresponsibility for payment of all bills in connection with this clinic lies with the patient.

Payment is expected at the time of service, all Deductibles, Co-insurance, andcopays will be collected in full.

Consent to Treatment or Testing with Liability Release:
**You authorize Complete Care Health Services (CCHS), its authorized subsidiaries and technicians to administer treatment and/or testing. Furthermore, while the chance of injury is slim, you agree to hold CCHS and its staff without fault for any injuries that may occur during the procedures or advice you have had done for you. Special note to patients with breast augmentation, although rare there may be risk of implant rupture - Please advise your Chiropractic Physician before any manipulation procedures.

Verification of Non-Pregnancy:
**You attest, to the best of your knowledge, that you are not pregnant, nor is the pregnancy suspected or confirmed at this particular time. If you think you might be pregnant, please advise your physician.

Release of Patient Records:
**You authorize CCHS to furnish your insurance carrier, attorney, and/or referring physician with documentation / reports relating to your case history, examination, diagnosis, treatment, and prognosis. This release of records is pursuant to only the representative above, and only for the accident/illness for which you are being treated. Furthermore, CCHS has the right to release any and all records required for remuneration purposes. Fees relating to such records are the patient’s responsibility.

Missed Appointment Notice:
**If you cannot make an appointment and need to cancel, we require 24 hours advance notice. Should we not receive such notice a $50.00 no show fee will be assessed to your account. This is a non-reimbursable fee that your insurance carrier does not pay and is your sole responsibility.

Returned Checks:
**All returned or unpaid checks will have a $45.00 returned check fee assessed to your account.

Verification of Information:
**Any information asked of me is / will be accurately given. I understand that providing incorrect information can be dangerous to my health. I authorize CCHS to release any said information, including the diagnosis, the records of any treatment and/or examination rendered to me during my care, to a third party payer and/or healthcare practitioners.

I also authorize payment to be made directly to CCHS and the amount due for all service charges for myself or my eligible dependents. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for all services rendered on my behalf or my dependents. Any collection fees, court costs, reasonable attorney fees, or returned check fees are the responsibilities of the person(s), including parent or legal guardian, named on theaccount.

I certify that I have read and understand the above information to the best of my knowledge.

I grant permission for my child to receive any care including consent to evaluate and treat the minor and/or child.