PATIENT INFORMATION

PATIENT INFORMATION
Full Legal Name:

First NameLast Name
Preferred First Name:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone #
Format: (000) 000-0000.
MF
Age
Birthdate

MonthDayYear
Date
Married:
Patient Employed by
Occupation
Family Medical Doctor
Phone
Format: (000) 000-0000.
Whom may we thank for referring you?
** Email:
example@example.com
(Used for Patient Appointment Reminders)
Primary Area of Problem or Reason for Visit: (Example: neck pain, lower back pain, numbless, tingling, routine visit, etc.)
PRIMARY INSURANCE

Please bring your insurance card with you to your appointment.
Insurance Company
ID #
Group #
Full Name of Person Responsible for Account
ADDITIONAL INSURANCE
YesNo
Insurance Company
I.D.
Group #
Subscriber Name
AGREEMENT & RELEASE
I assign directly to Cook Chiropractic all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether paid by insurance or not. I hereby, authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
Responsible Party Signature

Clear
Relationship
Date

MonthDayYear
Date

INFORMED CONSENT TO CHIROPRACTIC CARE
Please discuss any questions or concerns you may have, in regards to this consent, with the doctor before signing this informed consent. I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various models of physical therapy and diagnostic x-rays, on me (or on the patient named below, for whom I am legally responsible) by this office.
ASSIGNMENT OF BENEFITS for Cook Chiropractic & Rehabilitation
In consideration of your undertaking to render care, I agree to the following: Release of Information
1.) You are authorized to release any information you deem appropriate concerning my physical condition, any insurance company, attorney of adjuster in order to process any claim for reimbursement of charges by me at your treatment facility
2.) I authorize and assign to you, the medical provider, the right to receive direct payment from my attorney or any insurance company who may become obligated to pay me any sums. I further authorize the endorsement of my name to any draft containing my name which you are legally entitled.
3.) In the event any insurance company or attorney, obligated by contractual agreement to make payments, me for your service charges, refuses to make such payment upon demand by you, I hereby assign you to prosecute said action either in my name or you name as you otherwise resolve said claim as you see fit, I understand that whatever amounts you do not collect from said insurance proceeds (whether it be all or part what is due) shall be paid by me.
4.) I also assign to you, the medical provider, and grant the right to lien against many and all claims again any third party whose negligence may have caused my injury, including their insurance, up to the amount of bill for treatment.
5.) I waive the Statue if Limitations regarding my doctor's rights to recover from me directly.
Patient Signature:

Clear
Date:

MonthDayYear
Date
Parent/Guardian Signature (if patient is a minor):

Clear

COOK CHIROPRACTIC & REHABILITATION
AUTHORIZATION FOR APPOINTMENT REMINDERS AND HEALTHCARE INFORMATION
There may be times when the doctor or members of the doctors team, may need to use your private health information such as your name, address, phone number or clinical records in order to contact you in regards to:
- Appointment reminders,
- Information about alternative treatment,
- Or other health related information that may be of interest to you.
If you are not at home to receive an appointment reminder, a message could be left on your answering machine By signing the form, you are giving us authorization to contact you with these reminders and/or information.
Your Rights
You may restrict the individuals or organizations to which your PHI is released Or you may revoke your authorization to us at any time with the following rules: Your revocations must be in writing and mailed to us at out office address We will not be able to honor your revocation request if: If we have already released your private health information before we received your request to revoke the authorizatio If you were required to give your authorization as a condition of obtaining insurance, the insurance company may have. right to your private health information should they decide to contest any of your claims.
Information that we use or disclose based on the authorization you are giving us may be subject to re-disclosure by anyone that has access to the reminder or other information and may no longer be protected by the federal privacy rules
If you do not give us authorization, it will not affect the treatment we provide to you or the methods we use to oblain reimbursement for-services rendered to you.
You have the right to inspect or copy the information that we use to contact you for appointment reminders, informatior. about treatment alternatives, or other health related information at any time.
My signature authorizes you to disclose my private health information in the manner described above.
Patient Signature

Clear
Month/Day/Year

MonthDayYear
Date

FINANCIAL POLICY
As a courtesy to our patients, we offer the following billing options. Please mark the one that applies to you and sign at the bottom of the page.
PRIVATE PAY
I will pay for all services, as they are rendered, and submit my own insurance claims.
GROUP/HEALTH/PERSONAL HEALTH INSURANCE
I would like to assign my benefits to your office and have you submit my insurance claims for me. I understand that I am responsible for whatever co-payment, deductible, and non-covered services that my plan has set forth. I will pay the co-payment, deductible, and non-covered services that I am responsible for, as laid out by my plan. I understand that if my insurance company does not pay the balance within 45 days of submission, I am responsible for the entire balance overdue.
AUTO ACCIDENT / PERSONAL INJURY
I was involved in an automobile accident/personal injury and would to like to assign benefits to your office and have you submit all charges to insurance company for me. I will sign all liens necessary to protect your office. I also understand that regardless of settlement, I am personally responsible for the entire balance. If for some unforeseen reason your office is not paid within 45 days of claim submission, I will personally pay the entire overdue balance.
WORKER'S COMPENSATION
I was involved in an injury at work. I will see to it that all appropriate paper work is filed by my employer (i.e., accident report, etc.). I understand that it is my right as a Pennsylvania citizen to have any bills incurred as a result of a work-related accident paid for. I will read the Pennsylvania worker's compensation pamphlet to better understand that if this is the case, my rights may have been violated and I have the option to seek legal counsel.
MEDICARE
I am a Medicare participant and will pay for services as they are rendered. I understand that your office does not accept assignment of benefits for Medicare but will submit all charges to Medicare for me. I have read and signed the Medicare Act form and fully understand what services are covered.

COOK CHIROPRACTIC & REHABILITATION
Dr. Scott R. Cook
266 South 7^th St.
Indiana, PA 15701

Telephone: (724) 465-9160
Fax: (724) 465-9161
AUTHORIZATION FOR RELEASE OF RECORDS

This page is used if we would need to request records from another facility. PLEASE SIGN ONLY at the bottom of the page under patient signature.
TO
COOK CHIROPRACTIC & REHABILITATION
FACILITY HOLDING RECORDS:
(Complete Address)
COPIES OF MY MEDICAL RECORDSCOPIES OF MY X-RAYSCOPIES OF LIMITED RECORDS (i.e. lab/x-ray reports, date):
FACILITY RECEIVING RECORDS:

COOK CHIROPRACTIC & REHABILITATION
266 SOUTH SEVENTH ST., SUITE B
INDIANA, PA 15701
(724) 465-9160
PATIENT'S FULL NAME:
PATIENT'S BIRTHDATE:

MonthDayYear
Date
xPATIENT'S SIGNATURE:

Clear
DATE:

MonthDayYear
Date
Should be Empty:

PATIENT INFORMATION

PRIMARY INSURANCE

ADDITIONAL INSURANCE

AGREEMENT & RELEASE

CHECK IF YOU HAVE THESE HABITS

CHECK IF YOU HAVE EVER HAD or BEEN:

PREGNANCY DISCLAIMER

INFORMED CONSENT TO CHIROPRACTIC CARE

ASSIGNMENT OF BENEFITS for Cook Chiropractic & Rehabilitation

COOK CHIROPRACTIC & REHABILITATION

AUTHORIZATION FOR APPOINTMENT REMINDERS AND HEALTHCARE INFORMATION

Your Rights

FINANCIAL POLICY

PRIVATE PAY

GROUP/HEALTH/PERSONAL HEALTH INSURANCE

AUTO ACCIDENT / PERSONAL INJURY

WORKER'S COMPENSATION

MEDICARE

AUTHORIZATION FOR RELEASE OF RECORDS