• Confidential Patient Data

    If you need any assistance completing this form, please ask the receptionist.

  • PATIENT INFORMATION

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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • MEDICAL / FAMILY HISTORY

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  • Consent for Chiropractic Care

  • I hereby request that Dr. Dennis Royal, D.C. provide chiropractic service for me (or my minor child, whose name appears below), I understand that care is to be provided by Dr. Dennis Royal, D.C. or his designated assistant. Dr. Dennis Royal, D.C. will discuss my care with me and I understand that:

    1. The purpose of chiropractic care is to contribute to health by location, analysis, and correction of vertebral subluxations for the restoration of normal nerve functioning.
    2. Chiropractic is a separate and distinct profession is not the practice of medicine. Therefore, diagnosis of medical conditions is not a primary goal. However, I will be informed of abnormal findings.
    3. Chiropractors do not give medical advice, nor do they discourage me from receiving medical advice. If deemed advisable, Dr. Dennis Royal, D.C. will refer me for medical advice and/or diagnosis. Dr. Dennis Royal, D.C. will offer service with all possible diligence.
    4. Dr. Dennis Royal, D.C. uses only chiropractic methods that are taught in accredited colleges and appropriate techniques will be selected for my spinal care based upon standard professional protocols.
    5. Chiropractic adjustments are exceedingly safe when applied properly. However, all actions in life come with some risk, including chiropractic adjustments.
    6. Although the risks are minimal, there have been rare reports of vertebral artery damage, fractures, and aggravation of disk conditions associated with chiropractic procedures.
    7. Because a small force is introduced to the spine during adjustments there may be temporary minor musculoskeletal discomfort.
    8. I am an active participant in my chiropractic care, and I am therefore invited to ask any question or express any concerns that I may have.
    9. That I am free to withdraw my consent and discontinue care at any time.
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  • In consideration of the willingness of Royal Chiropractic Care to treat me on credit without demand for payment at the time that services are rendered, I     hereby agree and stipulate as follows. 

  • Please initial each line.

  • I acknowledge that I remain personally liable for the total amount due to Royal Chiropractic Ceneter for services rendered, including any balance remaining after the application of insurance payments, settlement, or judgement rpoceeds.

     I acknowledge that I have 120 days after Royal Chiropractic Center has sent my Medical Claim to the adjuster or attorney to settle my outstanding balance.

    I acknowledge that theree letters will be mailed regarding any outstanding balance that is on my account once 120 days have passed.

    I acknowledge that I will be sent to Collection Solutions of Virginia if my account is not resolved after 120 days.

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  • ASSIGNMENT OF BENEFITS

  • In consideration of the willingness of Royal Chiropractic Care to treat me on credit without demand for payment at the time that services are rendered, I      hereby agree and stipulate as follows:

    I irrevocably assign to Royal Chiropractic Center any proceeds or compensation that I am or may become entitled to receive as a result of injuries that occurred on   Pick a Date   to the extent of the chiropractic services rendered. I make this agreement without prejudice to any rights I may have prosecute legal claims against any party who may be liable for my injuries, but I hereby authorize and instruct you to pay directly to Royal Chiropractic Center, from any disability benefits, judgments, settlements, or proceeds of any kind that would otherwise be payable to me, such sums as are due or may become due to Royal Chiropractic Center for its services rendered.

    I appoint Royal Chiropractic Center as my attorney in fact to affix my name as an endorsement upon the reverse of any check personally or draft upon which I am a named payee and to deposit said check or draft and apply the proceeds to any unpaid balance I may have with Royal Chiropractic Center.

    I authorize Royal Chiropractic Center to release to any insurer with applicable coverage, or to my attorney, or successor attorney any information regarding my injuries, prior medical history, or treatment as may be necessary to facilitate collection of proceeds under this assignment.

    I acknowledge that I remain personally liable for the total amount due to Royal Chiropractic Center for services rendered, including any balance remaining after the application of insurance payments and settlement or judgement proceeds. If Royal Chiropractic Center is required to take legal action against me to recover any unpaid balance pm my account, I agree to reimburse Royal Chiropractic Center for its costs of recovery including reasonably attorney’s fees.

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  • NOTICE OF LIEN

  • Pursuant to N.C.G.S. 44-49 and 44-50, Royal Chiropractic Center hereby asserts and gives notice of a lien upon any sums recovered in damages for personal injury in any civil action and also upon all funds paid to above-named patient in compensation for or settlement of injuries sustained, whether in litigation or otherwise.

    Royal Chiropractic Center hereby requests that if its claim is not paid in full from the foregoing proceeds, a full disclosure and accounting of proceeds be provided in conformity with N.C.G.S. 44-50. Royal Chiropractic Center agrees to be bound by any confidentiality agreements regarding the contents of the accounting.

  • The following items will be added to your bill at the end of your personal injury treatment if INITIALLED. If you choose not to have the following items added, DO NOT INITIAL.
    Insurance companies have the choice to APPROVE or DENY listed items based on medical necessity. If approved, items will be given to patient once claim has been paid in full.
    Initial the following items that you would like to be included in your personal injury claim:
    Cervical Pillow
    Tens Unit
    Lumbar Support (car)
    Cervical Collar
    Lumbar Belt
    Back Brace

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  • PAIN DIAGRAM

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  • On the diagram below, please indicate where you are experiencing pain and other symptoms. Indicate on the line below how you would describe your present pain by placing a circle around the number between the two extremes.

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  • A = Aching B = Burning
    N = Numbness P = Pins & Needles
    S = Stabbing O = Other

  • NOTE!

  • Payment is expected as services rendered; therefore please understand that payment for services rendered on the first visit is due prior to your leaving the office unless other arrangements are made (i.e. medical insurance, Worker’s Compensation, attorney, or automobile medical coverage, etc.) Upon release from care, if no payment has been received in 90 days, Royal Chiropractic may directly bill the insurance company (i.e. med-pay, health insurance, liable party, etc.) for payment toward your outstanding medical bill.

  • Methods of Payment

  • CASH / CHECK / VISA / MASTERCARD

     

    Any checks that are returned will be charged with an insufficient fund charge in the amount of $25.00. Also, a cash payment will be collected for the services that are provided on that day in the amount of the check. If your case is not paid out the rest of the bill will be patient responsibility.

    The payment policy has been explained to me and all questions have been answered to my satisfaction. I understand that I alone am ultimately responsible for paying for services rendered at Royal Chiropractic Center. I also understand that at any time Royal Chiropractic Center can request that I pay all or part of the remaining balance on this account. If necessary I also agree to pay and/or all expenses for collecting fees, including legal fees.

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  • MISSED APPOINTMENT POLICY

  • At Royal Chiropractic Center, your time is valued. Dr. Royal strives to see patients in a timely manner. We respect your time and ask you to respect our time and other patients’ needs by keeping your appointment. Each appointment time slot is important and cannot be recovered if a patient chooses not to keep their appointment. We collect fees to ensure that Dr. Royal can continue to see patients. Please keep in mind that each skipped or missed appointment is not just time lost, but also time when other patients cannot be seen.

    Please refer to the guidelines below to learn more about our missed appointment policy:

    • It is your responsibility to provide us with a working telephone number to allow us to communicate important information, such as x-ray results, and provide telephone reminders of scheduled appointments. Having a valid telephone number is truly important; please help us maintain your records.
    • Effective July 1, 2005, each missed appointment will be flagged and you will receive a notice that you have missed your appointment. In addition, your account will be assessed a $10.00 missed appointment fee. Please note that the fee will not be billed to your insurance.
    • Any cancellation not made at least 24 hours before the scheduled appointment is considered a missed appointment and subject to the terms above.
    • If you arrive 20 minutes late for your scheduled appointment without prior notification to our office, this may also be considered a missed appointment. Please remember that communicating with our office is critical to us providing you with quality health care.

    We understand that circumstances occur that do not allow you to keep your scheduled appointment. If this is the case, please call and discuss this with the office staff as soon as possible. We will waive the cancellation fee for this appointment as long as you do not have a history of cancellations. Our schedule fills up quickly, and this will allow other patients to fill those slots.

    We realize that there are times that you may arrive for a scheduled appointment time and are not able to be seen promptly at your appointment time. Please know that we go out of our way to make certain that this does not happen; however, due to patient emergencies or other unexpected incidents, our schedule may occasionally fall behind.

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  • AUTOMOBILE ACCIDENT QUESTIONNAIRE

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  • THE FOLLOWING QUESTIONS PERTAIN TO YOU AND THE VEHICLE YOU WERE IN:

  • THE FOLLOWING QUESTIONS CONCERN THE OTHER VEHICLE INVOLVED IN THE ACCIDENT:

  • CONDITIONS AT THE TIME OF THE ACCIDENT:

  • THE FOLLOWING QUESTIONS CONCERN THE MOMENT OF IMPACT OF THE ACCIDENT:

  • AS A RESULT OF THE FORCE OF THE COLLISION, WHICH OBJECTS IN THE VEHICLE DID YOUR BODY STRIKE?

  • THE FOLLOWING QUESTIONS CONCERN THE TIME PERIOD IMMEDIATELY FOLLOWING OF THE ACCIDENT:

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  • NECK PAIN DISABILITY QUESTIONNAIRE

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  • Please mark the ONE choice from EACH group that best describes you.

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  • REVISED OSWESTRY LOW BACK PAIN DISABILITIES QUESTIONNAIRE

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  • Please mark the ONE choice from EACH group that best describes you.

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  • ACTIVITIES OF DAILY LIVING

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  • 0 = No affect
    1 = I am aware of my problem when I do this activity (Mild)
    2 = I don’t want to do this activity because of my problem (Moderate)
    3 = I can’t do this activity at all (Severe)

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  • INSTRUCTIONS: Please circle the statement that best apply to you.

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  • No bending

    • Do not lift anything heavier than 5 to 10 pounds. A gallon of milk weighs about 8 pounds. Be sure to hold objects you lift close to your body.
    • Do not bend forward or squat down to pick up items off the floor.

    Certain positions and movements should be avoided during your recovery. This will help to control your pain and prevent injury as your back heals. Your doctor or others on your care team will tell you when it is safe to resume these activities.

    No lifting

    Please talk to your doctor or others on your care team if you have any questions.

    • Do not reach, stoop or bend forward at the waist more than 90 degrees.
    • Do not bend from side to side. Be sure to avoid resting in a position that has you bent to the side.
    • Do not twist your spine when turning. Shift your feet to turn your whole body instead.
    • Log roll to turn over in bed. Place pillows between your knees to keep your legs apart. This helps to keep your hips, pelvis and spine in alignment.
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  • ACKNOWLEDGMENT FORM

    Acknowledgment of receipt of notice of privacy practice

  • By signing below, I acknowledge that:

     

    • I am either the patient or the patient’s representative.
    • I have received a copy of the Notice of Privacy Practices for County / District Health Department.
    • I understand that I may contact the person named in the notice if I have questions about the content of the notice.

     

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  • Part 1: Complete if signature is requested, but not obtained

  • Part 2: Complete if Patient/Representative is unavailable to sign form on first date of service delivery

  •     Pick a Date   

  • Part 3: Complete if either Part 1 or Part 2 completed

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  • NOTICE OF PRIVACY PRACTICES

    This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

  • YOUR RIGHTS

  • Get an electronic or paper copy of your medical record
    You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this. We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

    Ask us to correct your medical record
    You can ask to correct medical information about you that you think is incorrect or incomplete. Ask us how to do this. We may say “no” to your request, but we’ll tell you why in writing within 60 days.

    Request confidential communications
    You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say “yes” to all reasonable requests.

    Ask us to limit what we use or share
    You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.

    ONLY if you pay for a service or health care item out-of-pocket, in full, at the time of service, can we comply with your request not to share that information for the purpose of payment or our operations with your health insurance. (i.e. - comply with your request not to file your claims to your insurance company). Otherwise, we will say “yes” unless a law requires us to share that information.

    Get a list of those with whom we’ve shared information
    You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we share it with, and why. We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

    Get a copy of this privacy notice
    You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

    Get someone to act for you
    If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.

    File a complaint if you feel your rights are violated
    You can complain if you feel we have violated your rights by contacting us. You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.ffs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.

  • YOUR CHOICES

  • For certain health information, you can tell us your choice about what we share.

    If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions. In this cases, you have both the right and choice to tell us:

    • Share information with your family, close friends, or other involved in your care
    • Share information in a disaster relief situation
    • Contact us for fundraising efforts

    If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

    In these cases we never share your information unless you give us written permission:

    • Marketing purposes
    • Sale of your information

    In the case of fundraising: We may contact you for fundraising efforts, but you can tell us not to contact you again.

  • OUR USES AND DISCLOSURES

  • How do we typically use or share your health information?
    We typically use or share your health information in the following ways:

    • Treat you
      We can use your health information and share it with other professionals who are treating you.
      Example: A doctor treating you for an injury asks another doctor about your overall health condition.
    • Run our organization
      We can use and share your health information to run our practice, improve your care, and contact you when necessary.
      Example: We use health information about you to manage your treatment and services.
    • Bill for your services
      We can use and share your health information to bill and get payment from health plans or other entities.
      Example: We give health information about you to your health insurance plan so it will pay for your services.

    How else can we use or share your health information?
    We are allowed or required to share your information in other ways—usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.
    For more information: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html

    Help with public health and safety issues
    We can share health information about you for certain situations such as preventing disease; helping with product recalls; reporting adverse reactions to medications; reporting suspected abuse, neglect, or domestic violence; and preventing or reducing a serious threat to anyone’s health or safety.

    Do research
    We can use or share your information for health research.

    Comply with the law
    We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

    Respond to organ and tissue donation requests
    We can share health information about you with organ procurement organizations.

    Work with a medical examiner or funeral director
    We will share information with a coroner, medical examiner, or funeral director when an individual dies.

    Address workers’ compensation, law enforcement, and other government requests
    We can use or share health information about you for workers’ compensation claims, for law enforcement purposes, or with a law enforcement official. We can also use or share health information about you with health oversight agencies for activities authorized by law or for special government functions such as military, national security, and presidential protective services.

    Respond to lawsuits and legal actions
    We can share health information about you in response to a court or administrative order, or in response to a subpoena.

  • OUR RESPONSIBILITIES

  • We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

    For more information: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html 

     

    Changes to the Terms of This Notice
    We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website.

     

    Effective September 23, 2013

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