gladstonechiropractickc.com - New Patient Form

Welcome!

Thank you for choosing Gladstone Chiropractic as your health care provider. Our trained and caring staff is here to help you achieve maximum benefits from your chiropractic experience. Please allow our staff to photocopy your photo ID and all available insurance cards.
Name*

First NameMiddle NameLast Name
MaleFemale
Birth date*

MonthDayYear
Date
Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SingleMarriedWidowedDivorcedSeparated
YesNo
Number of children*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Employer*
Occupation*
Years*
Emergency Contact*

First NameLast Name
Emergency Contact Relationship*
Emergency Phone #*
Please enter a valid phone number.Format: (000) 000-0000.
Contact number where we can leave a message*
Please enter a valid phone number.Format: (000) 000-0000.
Email address*
example@example.com
List who we can speak to besides you (the Patient)*
How did you hear about us*
Date of injury or onset *

MonthDayYear
Date
Describe the major complaints that brought you to the office*
Background Questionnaire & Past History

Please answer the following questions to help us complete your medical profile
YesNo
Medical allergies*
YesNo
Please list below*
Never SmokerFormer SmokerCurrent "some days" smokerCurrent "every day" smoker
EnglishSpanishFrenchGermanChineseItalianOther
Family History
Anesthesia problemsDiabetesHypertensionStrokeHeart AttackCancerDepressionArthritisRheumatoidGoutKidney disorderBleeding/clottingOther
YesNo
Please list car accident, work or other injuries that required treatment*

List any surgeries you have had (don’t forget appendix, tonsils, ear tubes, wisdom teeth)

Rows	Surgeries	Date
1
2
3

YesNo
BalancedFairPoorExcessiveRestricted
YesNo
Type*
YesNo
How Long? *
CaffeineTobaccoNicotineAlcoholRecreational Drugs
Please describe your work. (If retired, describe work prior to retirement)
Physical laborProfessionalDriverClericalFactoryHomemaker
HeavyModerateMildSedentary
HighMediumLow
Signature of Patient (Signature of Responsible Party, if patient is a minor) *

Parent Name
Date*

MonthDayYear
Date

Designation of Authorized Representative
I, * do hereby designate Karissa D. Rasmussen, D.C. of Gladstone Chiropractic (hereafter referred to as “my doctor”), to the full extent permissible under the Employee Retirement income Security Act of 1974 (“ERISA”) and as provided in 29 CFR 2560-503-1(b)4 to act on my behalf to pursue claims and exercise all rights connected with my employee health care benefit plan, with respect to any medical or other health care expense(s) incurred as a result of the services I receive from the above named doctor. These rights include the right to act on my behalf with respect to initial determinations of claims, to pursue appeals of benefit determinations under the plan, to obtain records, and to claim on my behalf such medical or other health care service benefits, insurance or health care benefit plan reimbursement and to pursue any other applicable remedies, all in connection with medical or other health care expense(s) as the result of the services I received from my doctor.
Signature of Patient (Signature of Responsible Party, if patient is a minor) *

Patient’s Date of Birth
Date*

MonthDayYear
Date

GLADSTONE CHIROPRACTIC INFORMED CONSENT TO TREAT

I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic x-rays and/or other tests on me (or on the patient named below, for whom I am legally responsible) by Dr. Karissa D. Rasmussen and/or other licensed doctors of chiropractic who now or in the future treat me while employed by, working or associated with or serving as back-up for Dr. Karissa D. Rasmussen, including those working at the clinic or office listed or any other office or clinic.

I have had an opportunity to discuss with Dr. Karissa D. Rasmussen and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and procedures. I understand that results are not guaranteed.

I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment, including, but not limited to, fractures, disc injuries, strokes, dislocations, falls, dizziness, headaches, burns with modalities and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known, and is in my best interests.

I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.
Signature of Patient (Signature of Responsible Party, if patient is a minor)*
Date*

MonthDayYear
Date
Witness (Documenting Employee)
(Do not fill this item, it will be filled by one of our staff)
Date

MonthDayYear
Date

Insurance Payment Policies/Fee Disclosure

Code	Procedure	Fee
99201	Brief History/Exam	$100.00
99202	Initial History/Exam	$170.00
99203	Detailed History/Exam	$220.00
99213	Re-evaluation History/Exam	$150.00
99214	Detailed Re-evaluation History/Exam	$230.00
98940	1-2 Level Chiropractic Treatment	$50.00
98941	3-4 Level Chiropractic Treatment	$60.00
72040	Basic Neck X-rays	$105.00
72100	Basic Back X-rays	$105.00
97012	Traction	$35.00
97110	Therapeutic Exercises	$30.00
97140	Manual Therapy	$45.00

*All appointments are subject to a $25 fee, if not cancelled or rescheduled two hours prior to appointment time.*
- We will attempt to verify your insurance coverage. You are personally responsible for all services
  received and consent to being billed for non-covered charges.* Possible reasons for non-coverage:
  1. The service is or may be deemed investigational or experimental under the
  carrier's internal guidelines.
  2. The service is considered, or may be deemed, not medically necessary under the carrier's internal care or cost management guidelines.
  3. The service is not or may not be actually covered under the plan to which the above patient is subscribed.
  4. The service is not or may be deemed as not provided in accordance with the Provider's Agreement with the carrier or other requirements of the carrier's or managed care entity's internal guidelines.
  The carrier authorizes the provider to charge the patient for the above services so long as this disclosure is made and signed by the patient prior to the services being provided.
- If the doctor is a contracted provider for your health plan you are responsible for co-payments at the time of service.
- You authorize our office to release all information necessary to secure benefits. You authorize the use of your signature on any insurance submissions.
- If you have a balance for services, you agree to make a minimum payment of $50 per month or 20%, whichever is greater unless other arrangements are made with our office. Interest on accounts 60 days past due will be charged a setup fee of $4.00 plus interest at the rate of 12% annually.
- If the doctor is treating you under a lien for injuries sustained in an auto collision, there is an annual $75 administrative fee added to the account in lieu of interest.
  Regardless of the outcome of the case, all bills will be paid at 100% of the fee schedule.
- We accept cash, checks, debit cards, Visa, MasterCard, American Express, and Discover.
The amounts shown reflect insurance contracted rates and do not represent the patient’s financial responsibility.

Cash Payment Policies / Fee Disclosure
Fees quoted on request
All fees are payable at Time of Service unless prior arrangements have been authorized.

I have read and fully understand the above financial terms and prices.

Patient Financial Responsibility*:
The undersigned patient acknowledges that the Non-Covered status of the proposed service(s)
has been explained, and that a certain portion of the patient's care may not be covered by or has
not been authorized by the patient's insurance plan. The undersigned acknowledges that if any
portion of the care provided is not, or may not be, covered by insurance, then the undersigned
shall be responsible for payment, and shall make the necessary financial arrangements with the
healthcare provider to pay for these services.
Insurance Plan*
Signature of Patient (Signature of Responsible Party, if patient is a minor) *
Date*

MonthDayYear
Date
Photo ID*

Cancelof
Member ID*
Group Number*
Company (if applicable)*
Primary account holder*
Insurance ID*

Cancelof
* Please note that insurance companies do not guarantee the accuracy of the information they provide to us. You may wish to verify the coverage yourself by calling the number listed on your card.

ACKNOWLEDGMENT OF NOTICE OF PRIVACY PRACTICES
We must make a good faith effort to obtain a written acknowledgment that we have offered you a copy of our Notice of Privacy Practices no later than the date of first service delivery. If we are unable to obtain your acknowledgment, we must document why.

If there is an emergency, providing our Notice of Privacy Practices may be delayed until reasonably practicable after the emergency situation is resolved.

General referral information & spousal/family information may be shared without compromising the integrity of the patient-doctor privilege, unless specifically requested.
YesNo
Can we leave messages with anyone? Please list whom we can leave a message with below:*
List who we can speak to besides you (the Patient).*
Appointment Reminders & Events

Our office periodically sends out appointment reminders and event announcements.
I do NOT wish to participate in this program. (Initial)
PATIENT’S WRITTEN ACKNOWLEDGMENT

I understand a copy of the Notice of Privacy Practices is available for review at any time:
Signature of Patient (Signature of Responsible Party, if patient is a minor)*
Printed Name*
Date*

MonthDayYear
Date
Should be Empty:

Rows	Yes/No	Comments
Weight gain/loss, fatigue, insomnia?
Glasses/contacts, cataracts, glaucoma?
Sinus trouble, hearing loss, ringing?
Irregular heartbeat, high blood pressure?
Chest pain, fluttering in chest, coronary artery disease?
Shortness of breath, lung disease, persistent cough?
Decreased appetite, constipation, heartburn?
Nausea, diarrhea, hepatitis A, B, C?
Arthritis, fibromyalgia or osteoporosis?
Kidney stones, bladder or kidney infections?
Prostate problems?
Skin masses, blisters, dermatitis, eczema, psoriasis?
Problems with swallowing?
Seizures, tingling, numbness, severe headaches?
Anxiety, depression, other?
Increased thirst, diabetes, thyroid problems?
Bleeding or clotting problems?
Anemia, swollen or enlarged lymph nodes?
Hay fever, lupus or HIV/AIDS?

Welcome!

Background Questionnaire & Past History

Family History

Please describe your work. (If retired, describe work prior to retirement)

CASE HISTORY QUESTIONNAIRE

Females

Designation of Authorized Representative

Insurance Payment Policies/Fee Disclosure

ACKNOWLEDGMENT OF NOTICE OF PRIVACY PRACTICES

Appointment Reminders & Events

PATIENT’S WRITTEN ACKNOWLEDGMENT