THE RIVERMEAD POST-CONCUSSION QUESTIONNAIRE*

We would like to know if you now suffer from any of the symptoms given below. For each symptom below, please select the number that most accurately represents your symptoms.

 

0=Not experienced at all  1=No more of a problem  2=A mild problem

3= A moderate Problem   4=A severe problem

*King n., Crawford S., Wenden F., Moss N., and Wade D. (1995) J Neurology 242:587-592

ADVANCED HEALTH SOLUTIONS/ATLANTA INTERVENTIONAL PAIN MANAGEMENT

Your privacy and personal information are one of our highest priorities. This office is required to notify you in writing that by law, we must maintain the privacy and confidentiality of your Personal Health Information. In addition, we must provide you with notice concerning your rights or gain access of your health information, and the potential circumstances under which, by law, or as dictated by our office policy, we are permitted to disclose information about you to a third party without your authorization. Below is a summary of these circumstances.

PERMITTED DISCLOSURES:

1. Treatment purposes - discussion with other health care providers involved in your care.       

2. For MVA/S&F- to update attorney on case and obtain payment from your attorney or any other collateral source.

3.For workers' compensation purposes-to process a claim or aid in investigation.

4.Emergency-in the event of a medical emergency, we may notify a family member.

5.For public health and safety - in order to prevent or lessen a serious or eminent threat to the health or safety of a person or general public.

6. To government agencies or law enforcement - to identify or locate a suspect, fugitive, material witness or missing person.

7. For military, national security, prisoner and government benefit purposes.

8. Deceased persons - discussion with coroners and medical examiners in the event of a patient's death.

9. Telephone calls or emails and appointment reminders we may call your home and leave messages and send texts regarding a missed appointment or apprise you of changes of practice hours or upcoming events.

YOUR RIGHTS:

1.To receive an accounting of disclosures.

2. To recieve a paper copy of the comprehensive "Detail" Privacy Notice.

3. To request mailings to an address different than residence.

4. To request restrictions on certain uses and disclosures and with whom we release information to, although we are not required to comply. It, however, we agree, the restriction will be in place until written notice of your intent to remove the restriction.

5. To inspect your records and receive one copy of your records at no charge, with notice in advance.

6. To request amendments or information. However, like restrictions, we are not required to agree to them.

7. To obtain one copy of your records at no charge, when timely notice is provided. X-rays are original records, but you can request copies be made for you.

COMPLAINTS:

If you wish to make a formal complaint about how we handle your health information, please call the Office Manager at (770) 926- 9495. If they are unavailable, you may make an appointment with our receptionist or speak with a manager. If you are still not satisfied with the manner in which this office handles your complaint, you can submit a formal complaint to: DHHS Office of Civil Rights at 200 Independence Ave. SW, Room 509F HHH Building, Washington, DC 20201.

I understand the practices' duty or protect my health information and have conveyed my understanding of these rights and duties of the doctors. I further understand that this office reserves the right or amend this notice of privacy practice at any time and will make the new provision effective for all information that it maintains past and present. I am aware that a more comprehensive version of this notice is available to me upon request.

AHS/AIPM Corporate Office: 13190 Highway 92, Suite 70-90, Woodstock, GA 30188 Office (770) 926-9495 Fax (770) 926-9284

FINANCIAL AND ADMINISTRATIVE POLICIES

Welcome to our office. We are pleased to have you as a patient and committed to meeting your health care needs. It is our goal to provide you with the best possible treatment.

In order to accomplish this in a cost-effective manner, we ask that you adhere to the following guidelines:

1. You are ultimately responsible for charges of services rendered from our offices. We cannot guarantee coverage for any service provided by our office.

2. If you miss your appointment without notification, you will be charged a fee as below.

3. Massage Appointment canceled less than 24 hours' notice for appointments: $25.00

4. Medical Doctor Appointment canceled: $25.00

5. Returned payment for Non-Sufficient Funds: $30.00

6. Any unpaid balance past 90 days, will adhere to +7% interest charge will be applied monthly on the balance. Any outstanding bills will be

REFILL REQUEST and NURSE CALLS

We will try our best to refill prescriptions. Please allow up to 72 hours for your refill request to be filled. Please have the pharmacy fax the request for us at (770) 926-9284. Most medication refills may require a follow-up visit with the physician. Pain medication will not be called in after hours. An appointment with the physician will be required to replace lost or misplaced prescriptions.

Please allow our office 7-10 business days to complete your request. There might be a fee associated with a Physician completing these forms and you will be notified before it is done.

1. FMLA, disability, life insurance forms

2. Travel letters

3. School forms

4. Sports Physical forms

5. Other miscellaneous administrative forms required by third parties other than your health insurance company

We file insurance claims as a courtesy to our patients. Your health benefits and coverage are a contract between you and your insurance company, and we do not guarantee coverage for services rendered.

I have read and understand the financial policy stated above and agree to accept responsibility as described.

AHS/AIPM Corporate Office: 13190 Highway 92, Suite 70-90, Woodstock, GA 30188 Office (770) 926-9495Fax (770) 926-9284

PATIENT CONSENT FORM

The Patient Consent Form from Advanced Health Solutions outlines important information regarding the tests, diagnostics, and treatmentprocedures that may be necessary during your care. By signing this form, you acknowledge and agree to the following:

1.Understanding of Procedures and Risks:

•Scope of Procedures: Various medical procedures may be performed by healthcare professionals such as physicians, chiropractors,nurses, technicians, or physician assistants.

2.Material Risks: While these procedures are routinely performed without incident, they may carry risks including but not limited to:

•Physical Tests and Treatments: Allergic reactions, infection, severe blood loss, musculoskeletal or internal injuries, nerve damage, loss oflimb function, paralysis, disfiguring scars, worsening of the condition, or death.

•Medication Administration: Perforation, puncture, infection, allergic reactions, brain damage, or death.

•Blood or Tissue Sampling: Paralysis, nerve damage, infection, bleeding, and loss of limb function.

•Chiropractic Care: Sprain/strain injuries, disc irritation, fractures, and in extremely rare cases (one per one million to two million cervicalspine adjustments), vertebral artery injury leading to stroke.

3.No Guarantees Provided:

•Acknowledgment that the practice of medicine is not an exact science, and no guarantees have been made regarding the outcomes orresults of any procedures.

4.Provision of Accurate Medical History:

•Commitment to providing accurate and complete information about your medical history and conditions, understanding that healthcareprofessionals will rely on this information for your care.

5.Consent to Necessary Procedures:

•Consent for healthcare professionals to perform procedures they deem reasonably necessary or desirable, including unforeseenprocedures not known at the time of consent.

6.Informed of Nature and Risks:

•Confirmation that you have been informed in general terms about the nature and purpose of the procedures, the material risks involved,and any practical alternatives.

7.Opportunity to Ask Questions:

•Understanding that you can ask your physician or healthcare provider for additional information if you have any questions or concernsabout the procedures.

8.Additional Consent Documents:

•Awareness that your physician may request you to sign additional informed consent documents as needed.

•Material Risks: All medical procedures carry some level of risk, and it’s important to be aware of the potential complications listed.

•Patient Responsibility: Providing accurate medical history and information is crucial for safe and effective care.

•Communication: Open dialogue with your healthcare provider is encouraged to address any questions or concerns.

 

By signing the Patient Consent Form, you agree to proceed with the recommended medical care and acknowledge your understanding of theassociated risks and responsibilities outlined in the document.

AHS/AIPM Corporate Office: 13190 Highway 92, Suite 70-90, Woodstock, GA 30188 Office (770) 926-9495Fax (770) 926-9284

PATIENT PROVIDER CONTRACT AND PROMISSORY NOTE

This Agreement is between Advanced Health Solutions and Woodpark Family Chiropractic (the “Providers”) and the Patient. It outlines theterms under which the Providers will render medical, chiropractic, physiotherapy services, and diagnostic testing to the Patient.

1.Services and Payment: The Providers agree to offer essential healthcare services to the Patient. The Patient agrees to pay in full for allservices rendered, acknowledging that payment is their direct responsibility and not contingent upon any third-party settlements or claims.

2.Authorization to Insurance Carrier: The Patient authorizes the liability insurance carrier to disclose settlement information to theProviders. After settling any claims, the Patient directs the insurance carrier to include the Providers in any settlement payments or issueseparate checks to satisfy the Patient’s financial obligations to the Providers.

3.Authorization to Attorney: If represented by an attorney, the Patient directs their attorney to disclose settlement details to the Providersand to deduct medical expenses from any settlements to pay the Providers. The Patient remains personally liable for any unpaid balances.

4.Doctor’s Lien: The Providers may file a doctor’s lien under Georgia law (O.C.G.A §§ 44-14-470 and 44-14-471) to secure payment forservices rendered, especially in cases involving accidents.

5.Binding Arbitration: Any disputes related to the Agreement will be resolved through binding arbitration. The prevailing party is entitled toreasonable attorney’s fees and arbitration expenses.

6.Promissory Note Terms: The Patient promises to pay the full account balance within specified time frames related to service dates orsettlement events. Failure to pay results in the account becoming delinquent, with an interest rate of 16% per year and additional courtcosts and attorney fees amounting to 15% of the principal and interest due.

7.Termination Clause: Either party can terminate the Agreement at any time, but the Patient must settle any outstanding balances withinthree days of termination to avoid default.

8.Entire Agreement and Liability: This document represents the complete Agreement between the parties. The Patient acknowledges thatthey are personally liable for all charges, regardless of any actions or inactions by their attorney or outcomes of any claims.

9.Understanding and Acknowledgment: The Patient confirms they have read, understand, and agree to all terms stated in the Agreement.

Please review the corrected Agreement carefully to ensure it meets all legal requirements and consult a legal professional if you have anyquestions or concerns.

AHS/AIPM Corporate Office: 13190 Highway 92, Suite 70-90, Woodstock, GA 30188 Office (770) 926-9495Fax (770) 926-9284

Atlanta Interventional Pain Management

PATIENT PROVIDER CONTRACT AND PROMISSORY NOTE

 

This Agreement is between Atlanta Interventional Pain Management (the “Providers”) and the Patient. It outlines the terms under which theProviders will render medical, chiropractic, physiotherapy services, and diagnostic testing to the Patient.

1.Services and Payment: The Providers agree to offer essential healthcare services to the Patient. The Patient agrees to pay in full for allservices rendered, acknowledging that payment is their direct responsibility and not contingent upon any third-party settlements or claims.

2.Authorization to Insurance Carrier: The Patient authorizes the liability insurance carrier to disclose settlement information to theProviders. After settling any claims, the Patient directs the insurance carrier to include the Providers in any settlement payments or issueseparate checks to satisfy the Patient’s financial obligations to the Providers.

3.Authorization to Attorney: If represented by an attorney, the Patient directs their attorney to disclose settlement details to the Providersand to deduct medical expenses from any settlements to pay the Providers. The Patient remains personally liable for any unpaid balances.4.Doctor’s Lien: The Providers may file a doctor’s lien under Georgia law (O.C.G.A §§ 44-14-470 and 44-14-471) to secure payment forservices rendered, especially in cases involving accidents.

5.Binding Arbitration: Any disputes related to the Agreement will be resolved through binding arbitration. The prevailing party is entitled toreasonable attorney’s fees and arbitration expenses.

6.Promissory Note Terms: The Patient promises to pay the full account balance within specified time frames related to service dates orsettlement events. Failure to pay results in the account becoming delinquent, with an interest rate of 16% per year and additional courtcosts and attorney fees amounting to 15% of the principal and interest due.

7.Termination Clause: Either party can terminate the Agreement at any time, but the Patient must settle any outstanding balances withinthree days of termination to avoid default.

8.Entire Agreement and Liability: This document represents the complete Agreement between the parties. The Patient acknowledges thatthey are personally liable for all charges, regardless of any actions or inactions by their attorney or outcomes of any claims.

9.Understanding and Acknowledgment: The Patient confirms they have read, understand, and agree to all terms stated in the Agreement.

Please review the corrected Agreement carefully to ensure it meets all legal requirements and consult a legal professional if you have anyquestions or concerns.

AHS/AIPM Corporate Office: 13190 Highway 92, Suite 70-90, Woodstock, GA 30188 Office (770) 926-9495 Fax (770) 926-9284

Authorization to Release Medical Information / HIPPA

I understand, as set forth in the practice's Notice of Privacy Practices, I have the right to revoke this authorization, in writing, atany time by sending written notification to the Privacy Officer. I understand that a revocation is not effective to the extent thepractice has relied on the use or disclosure of the health information.I understand that I have the right to refuse to sign this authorization or to inspect (or copy) my protected health information tobe used or disclosed as permitted under federal and state laws. Furthermore, if the practice will receive payment for obtaining this information, I understand I will be notified of the same. I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipientand may no longer be protected by federal and state laws.Without express written revocation, this consent expires after one year.

AHS/AIPM Corporate Office: 13190 Highway 92, Suite 70-90, Woodstock, GA 30188 Office (770) 926-9495 Fax (770) 926-9284