• OLD PUEBLO CHIROPRACTIC, PC

    5102 E 5th St
    Tucson, AZ 85711
    Phone: 520-603-6248

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  • EN CASO DE ENERGENCIA A QUIEN LE PODEMOS HABLAR?

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  • ENTIENDO QUE SOY REPONSABLE POR CUALQUIER OBLIGACION DE SERVICIO CONTRAIDOS POR ESTA O CUALQUIERA OTRA AGENCIA Y TAMBEN DOY PERMISO QUE SE LE ATENDA A MI HIJO O HIJA POR SER MENOR DE EDAD

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  • Historial Médico para Paciente Nuevo

    Este formulario nos permite conocerla(o) mejor y saber cómo podemos ayudarle. No todas las preguntas son importantes para todos, pero entre más pueda contestar, más le podremos ayudar. Si hay alguna pregunta que le hace sentir incómoda(o), no la conteste y discútalo durante su visita. Gracias.
  • Si respondió si, por favor pare y hable con Old Pueblo Chiropractic

  • Persona llenando esta forma (que no es el paciente):

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  • Medical release of records

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  • I, *Autorizo.

  • To release my medical records, x-rays reports, or other information regarding my treatment, hospitalization, and/or out-patient care for my condition, including Psychological or Psychiatric, drug abuse, and Alcoholism to:

    Old Pueblo Chiropractic PC  
    5102 E 5th Street
    Tucson, Az 85711

                                                                                                                                                                         

    I understand that this authorization, except for action already taken, may be voided by me at any time.

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  • Obtener copia de su expediente medico de nuestra officina/ Release records from our office

  • I, * authorize Old Pueblo Chiropractic PC to release my medical records, X-ray reports, or other information regarding my treatment, hospitalization, and/or out-patient care for my condition, including psychological or psychiatric, drug abuse, and alcoholism to:


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  • I understand that this authorization, except for action already taken, may be voided by me at any time.

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  • CANCELLATIONS& NO SHOWS

  • We understand there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed care. Conversely, the situation may rise when another patient fails to cancel and we are unable to schedule you for a visit, due to a seemingly “full” schedule. If an appointment is not canceled at least 24 hours in advance you will be charged a $50.00 NO Show fee each missed appointment.

    INFORMED CONSENT TO CHIROPRACTIC TREATMENT

    I hereby request and consent to the performance of chiropractic treatments (also known as chiropractic adjustments or chiropractic manipulative treatments) and any other associated procedures: physical examination, tests, diagnostic x-rays, physiotherapy, physical medicine, physical therapy procedures, etc. on me by the doctor of chiropractic named above and/or other assistants and/or licensed practitioners.

    I understand, as with any health care procedures, that there are certain complications, which may arise during chiropractic treatments. Those complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, diaphragmatic paralysis, cervical myelopathy and costovertebral strains and separations. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to complications including stroke.

    I do not expect the doctor to be able to anticipate all risks and complications, and I wish to rely upon the doctor to exercise judgment during the course of the procedure(s) which the doctor feels at the time, based upon the facts then known, that are in my best interest.

    I have had an opportunity to discuss with the doctor(s) named above and/or with office personnel the nature, purpose and risks of chiropractic treatments and other recommended procedures. I have had my questions answered to my satisfaction. I also understand that specific results are not guaranteed.                .

    I have read (or have had read to me) the above explanation of the chiropractic treatments. By signing below, I state that I have been informed and weighed the risks involved in chiropractic treatment at this health care office. I have decided that it is in my best interest to receive chiropractic treatment. I hereby give my consent to that treatment. I intend for this consent to cover the entire course of treatment for my present condition(s) and for any future conditions(s) for which I seek treatment.

     

    SIGN ONLY AFTER YOU UNDERSTAND AND AGREE TO THE ABOVE

     

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  • DOCTOR/FACILITY LIEN

  • Contract for Medical Services

     The following are agreed upon terms between the undersigned patient and Old Pueblo Chiropractic. The terms of this agreement are to be strictly complied with and may not be altered unless agreed upon in writing by an authorized agent of Old Pueblo Chiropractic.

    Old Pueblo Chiropractic shall provide reasonable and medically necessary services to the undersigned patient by Old Pueblo Chiropractic and agrees to wait upon payment from the undersigned patient until monies are obtained from settlement, payment or judgment against a third party or collected from a first party source including but not limited to medpay/pip, uninsured or underinsured motorist coverages. This contract for providing medical services on a lien basis is additional security and guarantee for payment by the undersigned patient and patient's attorney beyond that protection provided by the current codified lien laws. The protection afforded to Old Pueblo Chiropractic by way of this agreement is in addition to and not In lieu of the current lien laws. It is understood that Old Pueblo Chiropractic would not be providing the reasonable and necessary medical service desired by the undersigned patient should all the terms of this agreement not be strictly adhered to.

    Old Pueblo Chiropractic will charge the undersigned patient commensurate with their standard fee schedule for all reasonable and necessary medical services provided.
    The undersigned patient understands that these are the amounts due and owing.

    Old Pueblo Chiropractic does not have obligation to bill any available health insurance for the undersigned patient. It is the patient's ultimate responsibility to submit any of the reasonable expenses necessitated by the accident to any applicable health insurance. Old Pueblo Chiropractic may as a courtesy bill available health insurance, but a decision or failure to do so does not in any way limit the undersigned patient's obligation to Old Pueblo Chiropractic for payment for all services rendered. As discussed herein below Old Pueblo Chiropractic will not agree to provide services to the undersigned patient should the patient choose to have reasonable and necessary medical expenses submitted for consideration to Medicare, Champus or any other plan that does not allow for balance billing.

    The undersigned patient acknowledges and agrees that if health insurance is billed and payments are made to Old Pueblo Chiropractic that this does not limit in any way Old Pueblo Chiropractic the right and ability to collect the total amount due and owing under the lien. Old Pueblo Chiropractic offers services on a lien basis expecting that full payment be made commensurate with the standard fee schedule regardless of any partial payments made by any health insurance.

  • Contract for Medical Services

    The undersigned patients authorizes to furnish his/her attorney and agents with a full report
    of the examination, diagnoses, prognoses and treatment and billing in regards to the injury(ies) from the motor vehicle accident occurring on or about to Old Pueblo Chiropractic. This shall include, as required by law, disclosure of HIV results and substance abuse issues.

    The undersigned patient authorizes and directs the attorney below and any other attorneys retained in the future to directly pay such sums that may be due and owing for professional services provided by reason of the accident, and to withhold such sums from any settlement, judgment, collateral source or verdict, including but not limited to liability, uninsured, underinsured, medpay/pip coverage or any other monies as may be required to adequately protect said provider. The undersigned patient further directs said attorney(s) to pay IN FULL all amounts owed Old Pueblo Chiropractic and mailed to the above address for said provider(s) arising out of treatment of my injuries from said accident. The undersigned patient acknowledge and agree not to contact any of the contract providers directly for payment obligation and understand that only an authorized Old Pueblo Chiropractic may provide balance verification and agree to any compromise under this lien contract.

    The undersigned patient irrevocably agrees to list Old Pueblo Chiropractic on any settlement draft(s)/check(s). The patient also agrees that this lien and all the rights granted to Old Pueblo Chiropractic will continue in full force and be binding upon me and counsel, should there be a change in attorneys in the future. Should the undersigned patient change attorneys, the undersigned patient will notify the lien holder promptly of the same and also notify said future attorney of all obligations arising out of this lien agreement. Should the undersigned patient not obtain new counsel, or not provide current whereabouts within a reasonable period of time (7 business days) to Old Pueblo Chiropractic, then Old Pueblo Chiropractic may deal directly with any applicable insurance, so as to satisfy said lien obligation.

    The undersigned patient agrees and acknowledges that this lien and all rights for collection of payment arising out of the same can and may be sold and reassigned and recognize that the purchaser of said lien will be entitled to all rights, as expressed here in.

    The undersigned patient understands that the patient is directly and fully responsible to Old Pueblo Chiropractic for all amounts due and owing and that this lien is being provided solely as additional protection to Old Pueblo Chiropractic. The undersigned patient provides this lien in consideration of Old Pueblo Chiropractic waiting upon payment.

  • Contract for Medical Services

    The undersigned patient further recognizes that payment to Old Pueblo Chiropractic is not contingent upon any settlement, judgment or verdict that I may or may not eventually obtain as reimbursement of said fee.

    The undersigned patient finally agrees as discussed herein above that the patient shall not
    submit, without express written permission from Old Pueblo Chiropractic, the medical bills arising out of such lien for payment to any private health plan or state or federal government sponsored health plan, including but not limited to, Medicare and Champus.

    The undersigned patient also further agrees that the patient will see Old Pueblo Chiropractic on a lien basis, and bill or allow for billing to any applicable private health insurance, should and only if said health insurance allows for balanced billing, as again discussed herein above. Should undersigned patient's health insurance not allow balanced billing, undersigned patient expressly agrees to forego submission to said health insurance, and allow and direct undersigned attorney or any future retained attorney to pay Old Pueblo Chiropractic all expenses out of any settlement proceeds including third and first party sources. If Old Pueblo Chiropractic elects to bill undersigned patient's health insurance or undersigned patient causes for payments to be made by any applicable health insurance, the undersigned patient will not nor will said undersigned attorney or future retained attorneys assert a claim for a pro rata reduction of said lien balance due to a common fund law argument in accordance with any other statutory/case law now or otherwise to come into existence.

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  • I, attorney of records for the above-recognized patient, agree to honor all the terms stated and agreed upon above and shall withhold all sums from any settlement, judgment or verdict including payments from all third and first party source, as may be required to adequately protect Old Pueblo Chiropractic.

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  • Please Note: This lien will not be accepted by Old Pueblo Chiropractic if any of the language is altered in any manner

  • HIPPA NOTICE OF PRIVACY PRACTICE

  • This NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO This INFORMATION. PLEASE REVIEW IT CAREFULLY.

    This Notice of Privacy describes how we may use and disclose your protected health information (PHI) to carry our treatment, payment or health care operations (TPO) for other purposes that are permitted or required by law. "Protected Health Information" is information about you, including demographic information that may identify you and that related to your past, present, or future physical or mental health or condition and related care services.

    Use and Disclosures of Protected Health Information:

    Your protected health information may be used and disclosed by your physician, our 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, pay your health care bills, to support the operations 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 health care 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 health care information may be provided to a physician to whom you have been referred to ensure that the 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 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, marketing, and fund raising activities, and conduction or arranging for other business activities. For example, we may disclose your protected health information 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 your protected health information, as necessary, 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 included as required by law, public health issues, communicable diseases, health oversight, abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, funeral directors, and organ donation.
    Required uses and disclosures under the law, we must make disclosures to you 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 REOUIRED 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 has taken an action in reliance on the use or disclosure indicated in the authorization.

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  • Cuestionario de Síntomas Post-Conmoción Cerebral

  • Después de una lesión en la cabeza o un accidente algunas personas pueden tener síntomas que pueden causar preocupación o molestia. Quisiéramos saber si usted tiene alguno de los síntomas siguientes. Debido a que muchos de esos síntomas ocurren normalmente, queremos compararlo a usted antes y después del accidente. Por favor señale el número que corresponde.

    0 = No lo he esxperimentado
    1 = Igual ahora que antes del accidente
    2 = Es un problema leve desde el accidente
    3 = Es un problema moderado desde el accidente
    4 = Es un problema severo desde el accidente

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