Patient Intake

Patient Intake - Adult

Please complete this form prior at least 24 hours prior to your appointment. Feel free to call if you have problems with this form. Our office number is 919-322-4383. We look forward to seeing you soon!
Name

First NameLast Name
Preferred name (if different than legal name)
Patient's Date of Birth

MonthDayYear
What sex were you assigned at birth?
Medicare Advance Beneficiary Notice of Non-coverage (ABN)

Please note: If Medicare doesn't pay for services recieved, 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 services listed below.

99203/99204 - Initial Exam - $175

99213/99214 - Re Exam - $20 with Adjustment

98940/98941 - Spinal Adjustment - $65

98943 - Extremity Adjustment - $55

97110 - Therapeutic Exercises - $22

97140 - Manual Therapy - $22/unit

97810/97811 - Acupuncture - $95

72082 - Full Spine X-Rays - $75

S8990 - Maintenance/Wellness Collective Adjustment - $55

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 reading this form.
- Choose an option below about whether to receive the above listed services.
  Note - If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.
This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 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.

CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call: 1-800-MEDICARE or email: AltFormatRequest@cms.hhs.gov
Options: Check only one box. We cannot choose a box for you.

Option 1: I want the services listed above. You may be asked to pay now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn't pay, I'm 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.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number

Area CodePhone Number
How did you hear about our office?
Where online did you see us?
Referring Friend/Family Member's Name
Referring Doctor's Name or Office Name
Referring Doctor's Office Phone Number

Area CodePhone Number
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number
Do you have a Primary Care Physician?
Primary Care Doctor's Name or Office Name
Physician's Phone Number

Area CodePhone Number
Health Insurance Provider

Other
Health Insurance Policy Information

We will verify your health insurance benefits and provide you with your financial responsibility at the start of care. Insurance benefits quoted to us are not a guarantee of payment or coverage. You are responsible for any amount shown on your EOB (explanation of benefits) once your claims have been filed. ******Please note: we are in network with Aetna, BCBS, Cigna, VA, and Medicare. Cash discounts and payment plans available if we are not in network with your insurance.
I understand that health insurance benefits quoted is not a guarantee of payment and I can reference my Explanation of Benefits (EOB) from my insurance company to determine final amounts. Please initial here:
Subscriber ID / Member ID
This is generally listed on the front of your insurance ID card and may be alpha numeric. Please include all characters listed including any listed suffix (01,02,03, etc)
Relationship to the Insured
Policy Holder's Name

First NameLast Name
Policy Holder's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current Condition Information

Please use the following fields to describe what brings you into our office.
What is your primary reason for coming in?
Are you pregnant?
What is your estimated due date?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please select the health concern that best describes what you are experiencing.

Other
Do any of these other conditions apply?
How long have you had this complaint

Other
When was the first time you noticed this complaint?
In the last two weeks how is your complaint changing?
What have you tried in the past to alleviate your symptoms?

Other
Do you have a history of any of the following conditions?
You will be evaluated for Chiropractic care on your initial visit. Please indicate any other services of interest.
Please list any other providers you have seen for this condition
When did this provider last treat your current condition? (estimate the date to the best of your ability)
Is your pain a result of any of the following?

Other
Please select all that apply

Other
Date of Accident

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Which seat did you occupy in the vehicle at the time of impact?

Other
Were you wearing a seatbelt?
Did the airbag deploy?
Which statement describes the accident best?
Pleas describe, to the best of your knowledge, what happened during the accident
Please select the most appropriate statement below regarding your medical treatment after the accident
What treatment have you received since the accident?
Do you have an open claim regarding the accident?
Do you intend to open a claim or get an attorney regarding this accident?
Auto Insurance Information
Please select the best option
Your Auto Insurance Carrier
Your Auto Insurance Policy Number
Your Auto Claim Number
Your Claim Adjuster's Name

First NameLast Name
Your Claim Adjuster's Phone Number

Area CodePhone Number
Do you have an attorney handling this claim?
Attorney's Name

First NameLast Name
Attorney's Phone Number

Area CodePhone Number
***PLEASE NOTE*** If you elect to pursue auto liability insurance to cover the cost of your care, you may not be able to retroactively bill your health insurance due to timely filing guidelines.

North Carolina Lien and Assignment of Benefits

I, the undersigned patient, do hereby authorize and direct my attorney and/or any applicable insurance carrier to pay directly to Gard Wellness Center such sums as may be due and owing for professional services rendered to me. This payment shall be deducted from any settlement, judgment, or benefits made on my behalf.

This lien and assignment is intended to protect the provider’s right to payment for services. I further agree that any unpaid balance for services rendered by Gard Wellness Center is ultimately my responsibility, regardless of the outcome of my claim, settlement, or insurance coverage.

In the event my attorney disburses settlement funds without satisfying this lien, I understand that I remain fully responsible for payment to Gard Wellness Center.

This lien and assignment shall be binding upon my heirs, legal representatives, and assigns, and may be revoked only with the written consent of Gard Wellness Center.
Full Name

First NameLast Name
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
By signing below, you acknowledge your understanding of responsibility of payment. The patient will be responsible for any balance not covered by auto or health insurance. *Please sign your full name*

The quality of my pain listed above is characterized as

Other
Does this pain radiate/shoot to any of the following areas (please indicate which side)?
This pain is

Please indicate how your condition impacts the following activities of daily living - an answer for each is required.

Rows	painful	some pain	not affected
bending
lifting
stairs
sitting
standing
walking
exercising
housework
kneeling

Please list any imaging you have had in the last three months (please bring recent images with you to your first appointment if possible)
I hereby authorize the aforementioned office and any of its appointed assistants to disclose the following information from the patient's healthcare record.
This information is to be disclosed to:

Agency/Business Name: Gard Wellness Center
Phone #: 919-322-4383
Fax #: 919-585-5568
Provider's Name:
Provider's Phone Number

Area CodePhone Number
Current Supplements/Over the Counter Medications - list none if you aren't currently taking any
Prescription Medications - list none if you aren't currently taking any
Do you use tobacco products?
How often to you consume alcoholic drinks?
Health History

Please indicate any past or present conditions listed below. Check all that apply.
General:
Musculoskeletal
Please list any broken bones or surgeries below and their date of occurance:
Neurological
Gastrointestinal
Cardiovascular / heart
Respiratory
Eyes / vision
Genitourinary
Endocrine, hematologic, lymphatic
Skin and breasts
Do you or your family have a history of any of the following? (check all that apply)
Who will be financially responsible for your care?
Financially Responsible Party's Name

First NameLast Name
Phone Number

Area CodePhone Number
Authorization for Communication - I authorize Gard Wellness Center to communicate with the individual(s) listed above as the financially responsible party regarding matters related to my care, including but not limited to scheduling, billing, insurance, and treatment-related financial responsibilities. I understand this authorization permits the release of protected health information as necessary for these purposes. Please sign below -
Associated Fees:

The doctor may decide it is medically necessary to include digital xray imaging of one or more areas of your spine or extremity, regardless of previous imaging. Women who think they may be pregnant will not receive xrays. Please let your doctor know if there is a chance you may be pregnant. Xrays are generally covered by your insurance subject to copay/coinsurance/deductible. Our office performs routine digital xrays yearly to optimize your care and make sure nothing is ever overlooked. These updated images are not covered by insurance and pricing will be discussed at the time of scheduling in the future.

Informed Consent:

As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation/ massage therapy / acupuncture / cold laser. These complications include but are not limited to: muscle strain, tenderness, fractures, soft tissue injuries, cervical radiculitis and costovertebral strains. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to complications including stroke. Some patients will feel some stiffness and soreness following the first few days of treatment. We use comprehensive examinations to screen for contraindications to care; however, if you have a condition that would otherwise not come to our attention, it is your responsibility to inform us.
HIPAA Privacy Practices Below
I have reviewed the HIPAA Privacy Practices for Gard Wellness Center (above) - Please sign in the box below:

Patient Intake - Adult

Health Insurance Policy Information

Current Condition Information

Auto Insurance Information

Health History

Functional Rating Index