Restrictions:

List any accidents or falls, and dates:

Operations and Procedures

Please check the correct box for each item below. Check at least one box for each sign or symptom listed: Never, Previously, or Presently.

General Symptoms

Muscles & Joints

Gastro-Intestinal

Cardiovascular

Eye/Ear/Nose/Throat

Skin or Allergies

Respiratory

Genito-Urinary

For Females Only

Do you have or have you had any of the following diseases?

I understand and agree that if I have health and/or accident insurance, these policies are an arrangement between the insurance carrier and myself. Further, I understand that this health care provider will prepare reports and forms to assist in reimbursement from the insurance company. Any amount authorized to be paid directly to this office will be credited to my account on receipt. However, I clearly understand and agree that all services rendered to me are my personal responsibility for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered to me will be immediately due and payable.

I hereby authorize the doctor to examine and treat my (or my child’s) condition as he/she deems appropriate through the use of Chiropractic Health Care, and I give authority for these procedures to be performed. It is understood and agreed the amount paid to the Doctor for imaging is for examination only and the negatives will remain the property of this office, being on file where they may be viewed.

We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we begin any health care operations, we must require you to read and sign this consent form stating that you understand and agree with how your records will be used. If you would like to have a more detailed account of our policies and procedures concerning the privacy or your Patient Health Information, we encourage you to read the HIPAA notice that is available to you at the front desk before signing this consent.

1. The patient understands and agrees to allow this chiropractic office to use their Patient Health Information (PHI) for the purposes of treatment, payment, healthcare operations, and coordination of care. As an example, the patient agrees to allow this chiropractic office to submit requested PHI to the Health Insurance Company (or companies) provided to us by the patient for the purpose of payment. Be assured that this office will limit the release of all PHI to the minimum needed for what the insurance companies require for payment. 
2. The patient has the right to examine and obtain a copy of his or her own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI. Our office is not obligated to agree to those restrictions.
3. A patient's written consent need only be obtained once for all subsequent care given the patient is in this office.
4. The patient may provide a written request to revoke consent at any time during care. This would not effect the use of those records for the care given prior to the written request to revoke consent but would apply to any care given after the request has been presented.
5. For your security and right to privacy, all staff has been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures in our office. We have taken all precautions that are known by this office to assure that your records are not readily available for those who do not need them.
6. Patients have the right to file a formal complaint with our privacy official about any possible violations of these policies and procedures.
7. If the patient refuses to sign this consent form for the purpose of treatment, payment and healthcare operations, the chiropractic physician has the right to refuse to give care.

I have read and understand how my Patient Health Information (PHI) will be used and I agree to these policies and procedures.

Cash Patients

Cash patients have chosen to forgo submission to insurance or we are not in network with your insurance. By opting for a Cash option, patients are required to pay the full amount due each day, thereby qualifying for our Time of Service Reduction in fees. You may then submit the bill to your insurance carrier for reimbursement, if chosen.

Group or Individual Insurance

Your insurance is an agreement between you and your insurance company, NOT between your insurance company and our office. We cannot be certain if your insurance covers Chiropractic care, although most policies do provide coverage. The amount they pay varies from one policy to another. When possible, we will call to verify benefits on your insurance; however, the benefits quoted to us by your insurance company is not a guarantee of payment. It is to be understood and agreed that any services rendered are charged to you directly and you are personally responsible for payment of any non-covered services, deductible, and co-payment. If we are not contracted with your designated insurance, you shall also pay the Full Amount due each day thereby qualifying for our Time of Service Reduction in fees. You may then submit the bill to your insurance carrier for reimbursement.

"On the Job" Injury (Worker's Compensation)

If you are injured on the job, your care should be paid for under your employer's Worker's Compensation insurance. You will need to inform your employer of the accident and obtain the name and address of the carrier of their insurance. If your employer does not provide us with this information, if a settlement has not been made within three months, or if you suspend or terminate care, any fees and services are due immediately. 

Medicare

We do accept assignment from Medicare. The check is usually sent directly to our office in payment of the services that Medicare will cover which for Chiropractors is ONLY manipulation of the spine. Medicare pays 80% of the allowable fee once the deductible has been met. You are required to pay the deductible and the remaining 20%. All other services we provide are NON-COVERED by Medicare and an ABN will be provided. These services include, but are not limited to: examinations, therapies, orthotics, supports, and/or nutritional supplements. Medicare patients are fully responsible for charges of non-covered services. Secondary insurances may or may not pay for these non-covered services. Our office completes and files the forms for Medicare at no charge.

Secondary Insurance

Please inform us of any Secondary Insurance you may have. We will assist if you need help with filing.

Insurance Forms/Payment

If you receive any correspondence from your insurance carrier pertaining to the care you have received at this office or a request of more information regarding your care, please bring it in as soon as possible. It is very important that we keep your file as up to date as possible. Occasionally, either by mistake, or due to provisions in your policy, the check issued by the insurance company for payment of services rendered in our office, may come to you instead of our office. If you should receive any unexpected check in the mail, please contact us to see if it does represent payment of your bill here.

If your insurance has a co-payment, it is DUE at the time of EVERY service.

Payment Options

We accept cash, check, MasterCard, American Express, Visa, or CareCredit (subject to approval). There is a $20.00 charge for returned checks.

I have read and understand the Financial/Payment Policy of Fulda Family Chiropractic. I understand that my insurance is an arrangement between myself and my insurance company, NOT between Fulda Family Chiropractic and my insurance company. I request that Fulda Family Chiropractic prepare the customary forms at no charge so that I may obtain insurance benefits. I also understand that if my insurance does not respond within 60 days, or if I suspend or terminate my schedule of care as prescribed by the doctors at Fulda Family Chiropractic, that fees will be due and payable immediately.

In compliance with requirements for government EHR incentive program

Demographics

Please choose specific answer or fill in as necessary. CMS requires providers to report both race and ethnicity.

Medications

Please fill in medication information including dosage/frequency or reaction type and onset date.

Medications - Allergic Reaction

Office Use Only:

Height: __________   Weight: __________   Blood Pressure: ______/______   Heart Rate: __________