New Patient Packet

Once you start, should you exit the browser your progress will not be saved.

This is an electronic form, and once you submit, our office staff will receive it.
Patient Information
Patient name (if patient is a minor, write the minor's name)*

First NameMiddle NameLast Name
Patient gender*
Patient date of birth*

MonthDayYear
Date
Home address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell phone*
Home/secondary phone
Email*
example@example.com
Race*
Ethnicity*
Language*
Social security number
Marital status*

SingleMarriedLegally SeparatedWidowedDivorcedDomestic Partner
Nearest friend or relative who may be called in case of an emergency*

NameNumberRelationsip
Who (or what source) referred you?*
Name of patient who referred you to us
Name of physician who referred you to us
Name of "other" source who referred you to us

Insurance - Primary
Staker Chiropractic & Associates only files with primary insurance. We do not file with secondary insurance.
Do you have insurance?*

NoYes
Insurance Company Name
What is the name of your "other" insurance?
Subscriber ID*
Is the patient the subscriber?

YesNo
Subscriber name*
Subscriber birth date*

MonthDayYear
Relationship to patient*
Insert a picture of the FRONT of your insurance Card (can not be a PDF)

Cancelof
Insert a picture of the BACK of your insurance Card (can not be a PDF)

Cancelof
Insert a picture of driver license or ID of Patient - If patient is a minor, must be ID of parent or legal guardian (can not be a PDF)

Cancelof

It is usual and customary to pay for services as rendered unless otherwise agreed.
Health insurance is a contract between YOU and the insurance company. We have NO influence as to what your insurance company will or will not authorize to pay. Should they not authorize to pay for treatment, it is an issue YOU WILL need to take up with them. We file your primary insurance for you as a courtesy. If for any reason your insurance company does not pay, then you will be personally responsible for any and all charges resulting from services rendered by Staker Chiropractic & Associates (Staker Chiropractic).

I do hereby authorize Staker Chiropractic to administer treatment, including x-rays and examination, necessary for treatment.

I do hereby authorize Staker Chiropractic to furnish my insurance company with a full report of physical examination, diagnosis, treatment, prognosis, etc. if requested by them.

I do hereby authorize and direct payment directly to Staker Chiropractic for chiropractic service rendered. I understand I am directly and fully responsible for my portion of the medical claims.

I have read and agree to be bound by the terms of this assignment of benefits.
Patient/parent signature*

Clear
Patient Name: {patientName45}
Date*

MonthDayYear
Date

Authorization for Releasing Information
Patient Name: {patientName45}
At our office, we strive to give the best customer service possible. We understand that patients may have family or friends request medical and billing information on their behalf, and we want to provide our best for them as well. However, due to HIPAA, we are unable to release information to anyone without the patient’s written consent. If you wish to allow access to your medical and billing information to family or friends, please provide their information and sign below.
Would you like to add someone to release medical and/or billing information?

YESNO
1. Name

First NameLast Name
1. Relationship to patient
2. Name

First NameLast Name
2. Relationship to patient
I {patientName45} understand that the information disclosed to any recipient listed above is no longer protected by federal or state law and may be subject to redisclosure by the above recipient. I understand that I have the right to revoke this consent in writing at any time.
Patient/parent signature*

Clear
Patient Name: {patientName45}

Patient Financial Policy
Staker Chiropractic & Associates is committed to providing our patients with the best possible care. To achieve this goal, it is important that you understand the following policies:

Health Insurance: We will gladly file your primary insurance for you when the following requirements are met:
- It is verified that you have current insurance coverage.
- Once you return all completed health questionnaires, when required by the insurance company.
- Once the chiropractic physician completes the initial examination, he/she will be able to determine if your recommended course of treatment involves services that are legally available to your insurance company.
While filing your primary insurance is a courtesy we extend to our patients, all charges are ultimately your responsibility. You must remember, your insurance is a contract between you and your insurance company. We are not a party to your contract.

If you have secondary insurance, it will not be filed by our office.

Auto accident or personal injury- It is necessary that you provide our office with all the appropriate information regarding your accident or personal injury claim. Our office will need the paperwork and authorizations in order to communicate with the party handling your claim and to coordinate payment. You are liable for any balance due, unless Staker Chiropractic enters into an agreement for reduction in fees.

Work related injury - You need to notify our office as soon as you arrive for your appointment. State law is specific on how we must bill your charges if you expect the insurance for your services.

Patient responsibility (copay/deductibles/coinsurance/self pay) is due at the time of service. Please note: charges for orthopedic supports, ice packs, vitamins and other non covered services are also due at the time of service.

Methods of Payment: Cash, Check, Visa, Mastercard, Amex, Discover, Apple Pay
Patient/Parent Signature*

Clear
Patient Name: {patientName45}
Date

MonthDayYear
Date

Notice of Privacy Practices - Acknowledgement & Consent

Acknowledgement for Consent to Use and Disclosure of Protected Health Information
Use and disclosure of your Protected Health Information (PHI)

Your PHI will be used by Staker Chiropractic & Associates (Staker Chiropractic) or may be disclosed to others 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 PHI 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 Staker Chiropractic.

Requesting a Restriction on the use or disclosure of your PHI.
- You may request a restriction on the use or disclosure of your PHI.
- Staker Chiropractic may or may not agree to restrict the use or disclosure of your PHI.
- If we agree to your request, the restriction will be binding with Staker Chiropractic. Use or disclosure of PHI in violation of and agreed upon restriction will be a violation of the federal privacy standards.
Revocation of consent

You may revoke this consent to the use and disclosure of your PHI. 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.

By my signature below I give my permission to use and disclose my health information. I also acknowledge that I have read the Patient Privacy Posting on the website www.stakerchiropractic.com.
Patient Name: {patientName45}
Patient/parent signature

Clear
Date

MonthDayYear
Date

Informed Consent to Chiropractic Treatment
I hereby request and consent to the performance of chiropractic assessments and other chiropractic procedures including various modes of physical therapy, and if necessary, diagnostic X-ray (or a patient named here for whom I am responsible) :{patientName45} by the chiropractic physicians at Staker Chiropractic & Associates (Staker Chiropractic).

I further understand that such chiropractic services may be performed by licensed Physician of Chiropractic that work at Staker Chiropractic who may treat me now or in the future. I have had the opportunity to discuss with my chiropractor and/or with other office or clinical personnel the nature and purpose of chiropractic adjustments and other procedures. I understand that results are not guaranteed.

I understand and am informed that, as in the practice of medicine and all healthcare, the practice of chiropractic carries some risks to treatment; including, but not limited to: fractures, disc injuries, strokes (CVA), dislocations and sprains. I do not expect the chiropractic physicians at Staker Chiropractic to be able to anticipate and explain all risks and complications. Further, I wish to rely on the chiropractic physician's judgement during the course of treatment to perform procedures which the chiropractic physician feels are in my best interest at the time, based upon the facts known.

I have read the above consent, and by signing below, I agree to the treatment recommended by my chiropractic physician. I intend this consent form to cover the entire course of treatment for my present condition(s) and for any condition(s) for which I seek treatment at Staker Chiropractic.
Patient/parent signature

Clear
Patient Name: {patientName45}
Date

MonthDayYear
Date
Should be Empty:

	Past	Present	Never
Headaches
Neck Pain
Upper Back Pain
Mid Back Pain
Low Back Pain
Shoulder pain
Elbow/Upper Arm Pain
Wrist Pain
Hand Pain
Hip/Upper Leg Pain
Knee/Lower Leg Pain
Ankle/Foot Pain
Jaw Pain
Joint Swelling/ Stiffness
Arthritis
Rheumatoid Arthritis
General Fatigue
Muscular Incoordination
Visual Disturbances
Dizziness

	Past	Present	Never
High Blood Pressure
Heart Attack
Chest Pains
Stroke
Angina
Kidney Stones
Kidney Disorders
Bladder Infection
Painful Urination
Loss Bladder Control
Prostate Problems
Abnormal Weight Gain/Loss
Loss of Appetite
Abdominal Pain
Ulcer
Hepatitis
Liver/Gallbladder Disorder
Cancer
Tumor
Asthma
Chronic Sinusitis

	Past	Present	Never
Diabetes
Excessive Thirst
Frequent Urination
Smoking/Use Tobacco Products
Drug/Alcohol Dependence
Allergies
Depression
Systemic Lupus
Epilepsy
Dermatitis/Eczema/Rash
HIV/AIDS

	Past	Present	Never
Birth Control Pills
Hormonal Replacement
Pregnancy

Patient Information

Insurance - Primary

It is usual and customary to pay for services as rendered unless otherwise agreed.

Authorization for Releasing Information

Patient Health Questionnaire - PHQ

Patient Health Questionnaire - part 2

Functional Rating Index

Patient Financial Policy

Notice of Privacy Practices - Acknowledgement & Consent

Informed Consent to Chiropractic Treatment