Patient Insurance Information

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1 Improving Lives & Performance Dr. Jeff Eidsvig, D.C., TPI- CGFI 3060 Communications Parkway, Suite #104 Plano, Texas New Patient Information / Change of Information : New Patient Change of Info Patient Name: Age: of Birth: Gender (circle one): MALE FEMALE SSN#: E- Mail: _ Address: City/State/Zip: Cell Ph#: Home Ph#: Work Ph#: Emergency Contact: Ph#: Referred By: Internet (Search Engine): Primary Care Physician: Ph#: Relationship Status (circle one): MARRIED SINGLE DIVORCED WIDOWED Patient Insurance Information Policy Holders Name: of Birth: Relationship to Policy Holder (circle one): SELF SPOUSE CHILD OTHER: Primary Insurance Company: Employer: Insurance Type (circle one): PPO POS HMO Subscriber ID#: Group #: Secondary Insurance Company: Employer: Insurance Type (circle one): PPO POS HMO Subscriber ID#: Group #: Authorization To Release Information: I hereby authorize the above named agency to release any/all treatment information requested by attorneys, physicians, insurance companies, employers, health care providers or any other entity which may be concerned with the payment of charges incurred for the treatment of services of Dr. Jeff Eidsvig, D.C., PLLC and authorize payment directly to Dr. Jeff Eidsvig, D.C., PLLC for services rendered. I accept responsibility for payment of any charges not paid or accepted by my insurance carrier.

2 Patient Intake Form Name: of Birth: : Contact PH#: 1. What is the main reason for your visit? 2. On the scale below, please indicate the severity of your main complaint (circle one) (None) (Severe) 3. Please indicate the overall improvement of your condition since your initial visit No Change 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% PAIN DRAWING ASSESSMENT Draw the location of your pain on the body outlines using the appropriate symbol. Include all affected areas. Mark the severity of your pain at the bottom of the page. 4. Use the diagram and symbols below to show where you are currently experiencing your main complaint today: ACHE BURNING NUMBNESS PINS & NEEDLES STABBING ZZZ BBB XXX = = = //// ZZZ BBB XXX = = = //// A = Aching C = Cramping N = Numbness P = Pins/Needles B = Burning D = Dull S = Sharpness ST= Stabbing ^^^ = Shooting /// = Throbbing +++ = Tingling T = Tightness O = Other: NO PAIN INTOLERABLE PAIN CIRCLE YOUR PAIN ESTIMATE 5. Please describe ALL details concerning your main complaint: I understand and agree that health and accident Insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that the doctor s office will prepare any necessary reports and forms to assist me in making collection from the insurance carrier, and that any amount authorized to be paid to the doctor s office will be credited to my account on receipt. However, I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care at this office, any outstanding charges for professional services rendered me will be immediately due and payable. Patient s Signature SS# Guardian or Spouse s Signature Authorizing Care Patient #

3 Patient History Patient Medications: (Please include Vitamins, Herbs, or Supplements) Past Medical Conditions/Hospitalizations/Surgeries Patient Allergies: (Please list ALL food and medicine allergies) Patient Family History: (Please list any medical conditions) Father: Brother(s): Grandmother(s): Mother: Sister(s): Grandfather(s): Information Regarding Current Symptoms and Past Care: (Please circle) Does the pain wake you up at night? Yes No Does the pain radiate from one region to another? Yes No Do you have noticeable weakness in any region? Yes No Do you have any bladder issues as a result of your condition? Yes No Have you had an MRI, X- Ray, CT Scan, or Bone Scan for your condition(s) within the past year? Yes No Please indicate when and which Imaging Facility: Social History Patient Occupation (Describe Environment): Alcohol: Yes No If yes, I have drink(s) per day or drink(s) per month. Tobacco: Yes No If yes, I smoke pack(s) per day or pack(s) per week. Illegal Drugs: Yes No If yes, what substance: Work History (circle one): Employed Unemployed Retired Homemaker Student Other Relationship Status (circle one): Single Married Divorced Widow

4 Treatment for Consent / HIPPA Form First Name: Last Name: My preferred method of communication regarding my medical conditions is indicated below: Cell Ph#: Home Ph#: E- Mail: If the above method is by phone, please check the appropriate box below (check one): Leave a message with detailed information Leave a message with call back number only Please note you are responsible for any charges incurred in receiving our communications. Insurance Authorization: I hereby authorize the release of medical or other information to my insurance company (via fax or e- mail) concerning charges/treatments provided to me by the doctor(s) listed. I hereby assign benefits and understand payment is due at the time services are rendered including my deductible, co- payment, co- insurance, or any other balances not paid by my insurance carrier (excluding contractual allowances) at the time of service. If, after 60 days, insurance payment has not been received, I understand all charges are my responsibility and payable immediately. Additionally, I understand I am responsible for providing the referral from my primary care physician. In the even such a referral has not been provided to the doctor(s) at Willow Bend Sports & Spine Center, I agree to pay for the service(s) at the time they are rendered. Consent For Treatment: I hereby authorize the doctor(s) at Willow Bend Sports & Spine Center and their staff to perform diagnostic tests and provide the necessary treatment for Chiropractic/Medical evaluation and health care for the above- mentioned patient. Patient Privacy Practices: I understand my rights regarding my protected health information governed by the Health Insurance Portability and Accountability Act of 1996 (HIPPA). I have been informed of, and given the opportunity to, review and secure a copy of Willow Bend Sports & Spine Centers Notice of Privacy Practices, which contain a complete description of the uses and disclosures of my protected health information. I understand the Notice of Privacy Information serve as: 1. A basis for planning my care and treatment. 2. A means of communication amongst health care professionals who contribute to my care. 3. A source of information for applying diagnosis and surgical information to my bill. 4. A means by which a third- party payer can verify services billed were actually provided. 5. A tool for routine health care operations, such as assessing care quality and reviewing the competence of health care professionals. I have read and understand the Patient Privacy Practices provided by Willow Bend Sports & Spine Center. I understand my personal health information will be used in treatment, payment, and operations, including those activities performed in order to improve the quality of care. I acknowledge receipt of this information and give authorization for the release of my Medical Records/Privacy Information to the following: I Authorize my Medical Records/Privacy Information to be Discussed/Disclosed to: Patient: Contact Name: PH#: PH#:

5 Insurance/ Financial Information and Policies First Name: Last Name: Financial Policies: Dr. Jeff Eidsvig, D.C., PLLC appreciates your confidence in choosing WBSSC to provide your health care needs. Our services imply a financial responsibility and obligation on your part to ensure full payment of our fees. WBSSC is committed to providing the best treatment possible for our patients and our fees reflect usual and customary charges for the North Texas area. As an important component of our professional relationship, following are WBSSC financial policies to ensure you have a clear understanding of our financial policies. Methods of Payment: As a courtesy to you, WBSSC will bill your insurance provider with a copy of your current insurance card (which must be presented at each visit or kept current on file in our office). If you do not have insurance or current insurance information, payment is due at the time services are rendered. If payment for an unpaid balance(s) has not been paid (or arrangements made for a payment plan) within 90 days of service, your balance will be sent to a collection agency for debt recovery. For your convenience, WBSSC accepts cash, checks, Visa, MasterCard, Discover, and American Express along with all debit cards. Please note there is a $50 fee charge for all checks returned from the bank due to insufficient funds. Insurance Participation: Dr. Jeff Eidsvig, D.C., PLLC participates with many PPO and POS insurance plans which allows WBSSC to accept assignment of benefits. If payment is not received from your insurance carrier with our contract limits, all balances will be the your responsibility. If WBSSC does not have a contract with your insurance carrier, you are responsible for payment in full at the time of service and considered a self pay patient. Insurance Plans: As a component of the parameters of our contracts, WBSSC collect co- payments, co- insurance, deductibles, and past due balances at each visit. If payments are not received and your account has a balance, you will be asked to reschedule your appointment until payment arrangements are made. Contracted Insurance Companies and Additional Fees: Dr. Jeff Eidsvig, D.C., PLLC is contracted IN NETWORK with most insurance carriers. Please ask our staff if your plan is included. NOTE: WBSSC offers procedures/services NOT covered by most insurance carriers; therefore, you will be responsible for full payment of these services/procedures when services are rendered. Procedures NOT Typically Covered By Insurance Carriers (You may file yourself): Hyperbaric Oxygen Therapy Treatments, Massage Therapy, and Biocorrect Orthotics I have read and understand the insurance and financial policies of Willow Bend Sports & Spine Center, the office of Dr. Jeff Eidsvig, D.C., PLLC

6 Office Policies First Name: Last Name: 10 Minute Late Policy: Patients arriving to our office over ten (10) minutes past their schedule appointment time will be asked to reschedule to another time and/or date. No Show Policy: Patients scheduled for appointments who fail to show up will be documented as a No Show and will be assessed and responsible for payment of No Show Fee : $100 for New Patients and $50 for Existing Patients. Walk In Appointments: Willow Bend Sports & Spine Center is an appointment only office and walk in appointments are not available. Payment: All payments are due at time of service. Due to the high cost of billing, patients unable to make payment at the time of service will be rescheduled and required to submit payment prior to another appointment another can be scheduled. Accepted methods of payment include cash, check, credit, and debit cards. Patients are responsible for their account balances, and expected to pay within 90 days or their balance will be sent to a collection agency. Per insurance company policies, benefits quoted to our staff via your insurance provider are not guaranteed until submitted and processed by your insurance provider. Patient Termination Policy: A patient may be terminated from the office at the discretion of the patient s doctor/staff. Common reasons include, but are not limited to: use of foul language, chronic non- compliance with recommended treatment, and abusive behavior to staff, doctors, visitors, or other patients. Medical Form or Medical Request Form Completion: Please be aware our staff requires 5-7 business days to complete all medical forms or requests. Copying of Medical Records: Patients requesting copies of their medical records will be assessed a $25.00 fee for the first 25 pages with an additional fee of $0.75/page. No fee will be assessed, when an abstract or referral is sent to a continuing care provider. A Medical Records Release of information must be signed and submitted to our office by the patient/or guardian of patient prior processing all requests. I have read and understand the office policies of Willow Bend Sports & Spine Center, the office of Dr. Jeff Eidsvig, D.C., PLLC

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