restorativespineandjoint.com - New Patient Form

Patient Form
Patient Name:

First NameLast Name
DOB:

MonthDayYear
Date
Date:

MonthDayYear
Date
Ht: Type a label Wt: Type a label Pulse: Type a label
BP: Type a label RESP: Type a label TEMP: Type a label
Chief Complaint:
What is the main reason for seeking treatment?
How long have you experienced your symptoms?
How bad are your symptoms at their worst?

1

2

3

4

5

6

7

8

9

10

1 is No Pain, 10 is Worst
How bad are your symptoms at their best?

1

2

3

4

5

6

7

8

9

10

1 is No Pain, 10 is Worst
DrivingWalkingWorkingBendingSportsSleepingOther:
RestIceHeatElevationNSAIDSPain medsNothing
ChiropracticPhysical TherapyInjections
What was the outcome?
Areas of complaint (please circle areas)

History of Present Injury/Illness
Neck Pain/StiffnessPins/Needles in ArmsLight Bothers EyesSudden Weight LossPins/Needles in LegsLoss of TasteBack Pain/StiffnessDepressionNauseaCold FeetArm/Hand PainFatigueNervousnessLoss of MemoryChest PainLeg/Knee PainSleeping DifficultiesTensionJaw ProblemsFeverHeadachesLoss of SmellCold SweatsConstipationFaintingDizzinessAllergiesStomach ProblemsShortness of BreathAsthmaBlurred VisionNight PainBowel/Bladder Changes
HypertensionHigh cholesterolMigrainesLiver DiseaseRheumatoid ArthritisHeart DiseaseHerniated discCancerKidney DiseaseFibromyalgiaPinched nervePacemakerUlcersOsteoporosisThyroid problemsStrokeArthritisDiabetesBleeding Disorders
YesNo
Do you have any Allergies to Medications?
Who is your primary care Doctor?
List all medications: (Be sure to include dosage and frequency):
Supplements (vitamins/herbs/minerals):
Surgeries and/ hospitalizations (type & date):
WOMEN ONLY:
Date of LMP:

MonthDayYear
Date
YESNO

Is there a family history of any of the following conditions? (Indicate family member including parents, grandparents & siblings)

Rows	No	Yes	Family Member
Heart Disease
Diabetes
Cancer
Arthritis

Other:
Intake of following:
Cigarettes
packs/day
Alcohol
drinks/week
Caffeine
cups/day
NeverDailyWeekly
WalksRunsSwims
Occupation:
SittingStandingLight LaborHeavy Labor

NEUROLOGICAL/ MRI/ VASCULAR PATIENT QUESTIONNAIRE

For any YES answer, please include details.
NOYES
Comment:
NOYES
Comment:
NOYES
Comment:
NOYES
Comment:
NOYES
Comment:
NOYES
Comment:
NOYES
Comment:
NOYES
Comment:
NOYES
Comment:
NOYES
Comment:
NOYES
Comment:
NOYES
Comment:
NOYES
Comment:
NOYES
AdvilAleveTylenolSteroidsOther:
0-3mos3-6mos6-12 mos12+mosOther
NOYES
If yes: When? Who ordered it? What was it ordered for? What facility?
NOYES
If yes: When? What kind? Who ordered it?

Patient Name:
DOB:

MonthDayYear
Date
Date:

MonthDayYear
Date

ADLS/IADLS

Rows	REQUIRES NO ASSISTANCE	SOME ASSISTANCE NEEDED	COMPLETE ASSISTANCE NEEDED	NOT APPLICABLE
BATHING/ GROOMING
DRESSING
ORAL CARE
TOILETING
TRANSFERRING
WALKING
CLIMBING STAIRS
EATING
SHOPPING
COOKING
MANAGING MEDICATIONS
USES THE PHONE
HOUSE WORK
LAUNDRY
DRIVING

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor’s office of any changes in my medical status. I also authorize the healthcare staff to perform the necessary services I may need.
Signature of Patient/ Parent or Guardian
Date

MonthDayYear
Date

Patient Information
SS #/SIN
Date of Birth

MonthDayYear
Date
MaleFemale
Patient’s Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email:
example@example.com
Employer Name:
MinorSingleMarriedDivorcedWidowedSeparated
Spouse or Patient’s Guardian name
Whom may we thank for referring you?
Person to contact in case of an emergency:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
In case of a medical emergency, if the patient is of school age 15+, it is ok to treat in my absence.
PARENT OR GUARDIAN SIGNATURE
DATE

MonthDayYear
Date
Responsible Party
Name of the person responsible for this account
Relationship to Patient
Driver’s License #
Date of Birth:

MonthDayYear
Date
YesNo
YesNo
If yes, complete the following:
Name of the insured
Relationship to patient
Birthdate

MonthDayYear
Date
SS#/SIN
Insurance Company
Group #
Subscriber #
Union or local #
Ins. Co. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CONSENT TO ELECTRONIC COMMUNICATIONS

I consent to receive communications from Restorative Spine and Joint via text message and/or email. I understand that these methods of communication may not be secure and may involve some risk to the privacy of my health information.
Signature:
Date:

MonthDayYear
Date
RESTORATIVE SPINE & JOINT CONSENT TO CHIROPRACTIC CARE

I consent to examination and chiropractic care, including manipulation, manual therapy, and related therapeutic procedures, as clinically indicated by the providers at Restorative Spine and Joint. If the patient is a minor, I certify that I am the parent or legal guardian and have authority to consent to treatment. I understand that the nature and purpose of care will be explained to me, that I may ask questions and refuse or discontinue treatment at any time, and that results are not guaranteed. I understand that risks may include, but are not limited to: increased pain or discomfort, fractures, disc injuries, strokes, dislocations, and sprains. Therapeutic procedures and exercise may also involve risk, including rare cardiovascular events. I understand that not all risks can be anticipated. By signing below, I consent to care provided by Restorative Spine and Joint.

This consent remains valid for ongoing and future care unless revoked in writing.
Patient Name:
Signature of Patient or legal guardian:
Relationship (if minor):
Date:

MonthDayYear
Date
ASSIGNMENT OF BENEFITS, LIMITED AUTHORIZATION, AND ERISA RIGHTS

I understand that I am financially responsible for all services rendered, regardless of insurance coverage. I assign and authorize payment of medical benefits directly to Restorative Spine and Joint. I authorize the use and disclosure of my health information for treatment, payment, healthcare operations, and insurance processing, in accordance with applicable law, including HIPAA and California law. If my plan is governed by ERISA, I assign the right to receive benefits, submit claims, appeal determinations, and obtain plan information related to services provided. This assignment is limited to payment matters and does not constitute a general power of attorney.
Signature of Patient or Legal Guardian:
Date:

MonthDayYear
Date
ACKNOWLEDGMENT OF NOTICE OF PRIVACY PRACTICES

I acknowledge that I have received or been offered the Notice of Privacy Practices and understand my rights. A copy is available upon request and on the practice website.
Patient Name:
Signature:
If Personal Representative, relationship:
Date:

MonthDayYear
Date
FINANCIAL POLICY

I understand that all charges are my responsibility regardless of insurance coverage, and that insurance is a contract between me and my insurer. As a courtesy, the practice may bill my insurance; however, verification of benefits is not a guarantee of payment. I am responsible for all co-payments, deductibles, co-insurance, and non-covered services.

If my claim is unpaid or denied, I agree to pay the balance due.

Personal Injury / Auto: I understand that third-party billing may be submitted, but I remain responsible for payment.

Medicare: I understand Medicare will be billed where applicable and I am responsible for non covered services.

WORK-RELATED INJURY DISCLOSURE

I certify that my condition is not work-related. I understand this practice does not treat workers’ compensation injuries and I may be referred if applicable.

ADDITIONAL TERMS

Time of Service: Discounts may apply only when payment is made at the time of service.

Missed Appointments: Less than 24-hour notice may result in a $40 fee. Repeated missed appointments may result in scheduling limitations or discharge from care. Collections: Delinquent accounts may be subject to collection efforts, and I may be responsible for associated costs as permitted by law.

AGREEMENT

I have read and understand this Financial Policy and agree to be responsible for payment.
Patient Name:
Signature:
Date:

MonthDayYear
Date
OUT-OF-NETWORK FINANCIAL DISCLOSURE

I understand that Restorative Spine & Joint may be out-of-network with my insurance. Reimbursement may be reduced or denied, and I am responsible for any difference between billed charges and insurance payment, including deductibles, co-insurance, and non-covered services.

Estimates are not guarantees of payment. I am responsible for all charges except where limited by law.
Patient Name:
Signature:
Date:

MonthDayYear
Date
Financial Policy

Welcome to our office! Your health is our chief concern and we strive for excellence in chiropractic care. In order to make the handling of your financial obligations as smooth as possible, please read and sign the following policy. If you have any questions, our staff will be happy to assist you.

General Insurance Information
Please remember that all health and accident policies are arrangements between you and the company that writes the policy. All charges in this office are your personal responsibility and all fees are charged directly to you. As a courtesy to you, we will prepare necessary insurance claim forms to assist in collections from your insurance company. We will also bill insurance on your behalf and will expect payment from them within 60 days. Should the claim remain unpaid over 60 days for any reason, we will then personally bill you for the balance, net 30 days. Please note that this office will not enter into dispute with an insurance company over your claim.

Your coverage (PPO, HMO, EPO, HSA, etc)
This office is under contract with many insurance plans. Please present your insurance card to the front desk so that we may make a copy for your file. On your behalf, we will immediately begin verifying your estimated coverage. You will need to sign the Signature on File/Authorization form. Your financial obligation may consist of a co-payment and/or a deductible. The co-payment will be either a fixed amount or a percentage of the charges. Co-payments vary from plan to plan but generally range from $5.00 - $30.00 per visit. PLEASE NOTE THAT YOU ARE RESPONSIBLE FOR PAYMENT OF ALL FEES FOR PROFESSIONAL SERVICES EVEN THOUGH YOU MAY HAVE INSURANCE COVERAGE-this means that should the insurer fail to pay sums due, you are responsible for the payment.

Worker's Compensation
With authorization to treat from your employer, if you are hurt on the job your care is handled 100% through eligible worker's compensation benefits.

Personal Injury
This category also includes automobile accidents. If you have medical coverage (med-pay) on your auto insurance policy, we will bill them directly for prompt payment of your care. This coverage is in place to immediately handle your medical needs regardless of who is at fault. If you are not at fault, you will not be penalized by your insurance company as they will collect for reimbursement from the responsible party. If med-pay is not part of your coverage, we will set up monthly payment arrangements upon your request. Please remember, you are directly responsible for payment of your bill.

Medicare
We are happy to accept Medicare patients, and we accept Medicare assignment. You will receive our MEDICARE ADVANCECED BENEFICIARY NOTIFICATION. Please read and sign this form. We will be happy to answer any questions.

Personal Pay/Time of Service
Because of decreased administrative costs, we are able to extend a time of service (T.O.S.) discount to our patients who do not have or choose not to use their insurance. To receive this discount, services must be paid for at the time they were rendered. The discount will not apply if we must send a bill for payment. If you have any questions regarding this time of service discount, please speak to our office manager. For Example:

Typical adjustment	$75.00
Payment at time of service	-$18.00
Balance	$57.00

No Show Policy
It is important to our patients that we stay on schedule and make ourselves available to those patients in need with minimal or no wait time. To make this happen, we work hard to keep on schedule and many times have a waiting list for patients needing care. If you must cancel an appointment, we understand that things come up. A courtesy phone call is very important. A “no-show” takes an opportunity away from another patient who may be wanting to get in sooner. To that end, our office has implemented a “no-show” fee of $40.00 which will be paid in full prior to the next scheduled visit.

•• ••

I HAVE READ AND UNDERSTAND MY RESPONSIBILITY CONCERNING PAYMENT/POLICIES IN THIS OFFICE. I agree to be responsible for payments of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed upon dates, I understand that a 1-1/2% late charge (18% APR) may be added to my account and the time of service discount will become void. If required, I also understand a check of my credit history may be made. I agree to pay all costs of collection, including attorney fees should legal action be necessary.

Patient Name
Patient/ Guardian Signature
Date

MonthDayYear
Date
Should be Empty:

Patient Form

Chief Complaint:

History of Present Injury/Illness

WOMEN ONLY:

Intake of following:

NEUROLOGICAL/ MRI/ VASCULAR PATIENT QUESTIONNAIRE

Patient Information

Responsible Party

Financial Policy