New Patient - Intake

Patient Demographics
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Best Contact Phone*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
How would you like us to contact you?*

EmailTextPhone
Gender assigned at birth*

MaleFemale
Do you identify as:

CisgenderTransgenderI would rather not sayOther

Financial Responsibility
Is your condition related to an accident or personal injury claim?*
What is your claim number?
Would you like us to bill an insurance company on your behalf?*
Name of Insurance Company
Primary Insured's Name

First NameLast Name
Insurance ID Number
Who will be financially responsible for this account?*

First NameLast Name
I, Name* , understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and me. I authorize payment from my insurance company directly to this office with the understanding that all monies will be credited to my account upon receipt. However, I clearly understand and agree that all services rendered are charged directly to me and that I am responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees or professional services rendered will be immediately due and payable. If not paid, I agree to pay all collection and legal fees associated with collection for professional services rendered by this office. I also understand that all outstanding service balances over 6 months will be subject to a 5% interest fee per month until the balance is paid. To avoid this fee a written payment agreement must be done in person at the office. Medicare and Insurance Patients: Integrative Health Solutions is a Medicare participating provider, along with several other insurances. Please be aware that Medicare and other insurances may cover only charges for adjustments, and NOT the initial examination NOR the yearly required re-examination. Please be aware that you will be responsible for these fees if they are not covered by your policy. LASER TREATMENTS are not billable to all insurance companies and/or policies and will be your responsibility in the event that laser treatment is not covered. By Signing at the end of this form I understand that I am financially responsible for this account.
Emergency contact name

First NameLast Name
Emergency contact phone number
Please enter a valid phone number.

Family History

List any family cancer, heart disease, diabetes, kidney disease, stroke, Alzheimer's, Parkinson's, Dementia, gout, liver disease, Metabolic Syndrome, vision loss or other for the following family members...
Mother
Father
Maternal Grandparents
Paternal Grandparents
Siblings
Aunts, Uncles, Cousins or other family members

Lifestyle
List your typical foods for breakfast, lunch and dinner
Do you drink...

CoffeeTeaSodaJuiceEnergy DrinksDairySoyWaterAlcohol
How committed are you to living a healthy lifestyle on a scale from 1-10, with 10 being the highest?

Required Documents
Advance Beneficiary Notice of Noncoverage (ABN)

NOTE: If Medicare does not pay for Exams, X-Rays, Low Level Laser Therapy, or Dry Needling which means that you may have to pay. Medicare does not pay for everything, even some care that you or your health care provider have good
reason to think you need. We expect Medicare may not pay for the procedures listed below.
Procedure Reason Medicare May Not Pay Estimated Cost

- Examination

Examinations are not a covered benefit under Medicare for Chiropractic
care.

Up to $150 - Average $58

- X-Rays

X-Rays are not a covered benefit under Medicare for Chiropractic care.

Up to $130 - Average $50

- Low Level Laser Therapy

LLLT is not a covered benefit under Medicare for Chiropractic care.

Up to $50 - Average $45

- Dry Needling

Dry Needling is not a covered benefit under Medicare for Chiropractic
care.

Up to $40 - Average $25

This notice gives our opinion, not an official Medicare decision. If you have any other questions on this notice or Medicare billing,
called 1-800-MEDICARE. (1-800-633-4227/TTY: 1-877-486-2048).
Signing below means that you have received and understand this notice. You may also receive a copy.

You have the right to get Medicare information in an accessible format, like large print, Braille, or audio. You also have the right
to file a complaint if you feel you’ve been discriminated against. Visit Medicare.gov/aboutus/accessibility-nondiscrimination
notice.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required
to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions,
search existing data resources, gather the data needed, and complete and review the information collection. If you have comments
concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard,
Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850

WHAT YOU NEED TO DO NOW:
• Read this notice so you can make an informed decision about your care.
• Ask us any questions that you may have after you finish reading.
• Choose an option below about whether to receive the procedures listed above.
Choose an option below about whether to receive the procedures listed above.*

I want the procedures listed above. You may ask to be paid now but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice. I understand that if Medicare doesn't pay, I am responsible for payment but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay you will refund any payments I made to you, less co-pays or deductibles.I want the procedures listed above but DO NOT bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.I don't want any of the procedures listed above. I understand with this choice I am not responsible for payment and I cannot appeal to see if Medicare would pay. I understand that my care will be limited to Chiropractic adjustment only.
Signature*

Powered by Jotform SignClear
Date signed*

MonthDayYear
Date
Should be Empty:

Patient Demographics

Financial Responsibility

About your condition

Personal Medical History

Maternal/Birth History

Family History

Lifestyle

Required Documents