Reminders will be given 48 hours in advance for all appointments.

Transcription

1 APPOINTMENT REMINDER FORM FOR CHIROPRACTIC PATIENTS Date: Name: Please check the box with the preferred way you choose to be notified of your appointment time (Please only select one option). Phone call reminders are no longer available for Chiropractic appointments. OR Text Message OR Cell Phone Carrier (Verizon, AT&T, Sprint, Etc ) No reminder Reminders will be given 48 hours in advance for all appointments. MISSED APPOINTMENTS: A 24 hour cancellation policy is in effect for all chiropractic services. We reserve the right to charge for missed appointments. If 24 hour notice is not given, you will be billed $30 for the session. If less than 24 hour notice is given, every effort by our staff will be made to fill the appointment from the Waiting List. If it cannot be filled, you will be charged. For VA patients If you miss more then 3 appointments without a 24 hour cancellation, our only recourse is to discontinue care.

2 COMPLETE CHIROPRACTIC & BODYWORK THERAPIES FINANCIAL POLICY/AUTHORIZATION AND ASSIGNMENT Thank you for choosing Complete Chiropractic & Bodywork Therapies as one of your health care providers. Please understand that payment of your bill is considered a part of your commitment here. The following is a statement of our Financial Policy, which we request you read, and sign prior to any treatment. All New Patient paperwork must be filled out and completed prior to seeing your practitioner. Full payment is due at the time of services rendered, unless special arrangements have been made in advance. I assign payment to be made directly to Complete Chiropractic & Bodywork Therapies for services billed to my insurance that are outstanding. We accept cash, checks or Visa/MasterCard. For massage therapy services not covered by your insurance, we accept cash or check only. Payment is made directly to the practitioner. INSURANCE: We are participating providers of BCBS Traditional and BCBS PPO. Any other insurance is Out of Network in our office. Some insurances do provide coverage for chiropractic services. Our Financial Coordinator Kendra, can call and check to see if your insurance may provide benefits for services received at our office. We ask that all co pays and deductibles be paid at time of service. I authorize the release of any information necessary to my insurance provider, attorney or adjuster, as needed to process my claims. Be aware that some, perhaps all, of the services provided may be non-covered services and not considered reasonable and necessary under the Medicare Program and/or other medical insurance. USUAL AND CUSTOMARY RATES: Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company s arbitrary determination of usual and customary rates. Adult patients are responsible for full payment at time of service. When an adult accompanies a minor they are responsible for the payment. An unaccompanied minor may make payment by credit card, cash or check at time of service. (continued on next page)

3 MISSED APPOINTMENTS: A 24 hour cancellation policy is in effect for all chiropractic services. We reserve the right to charge for missed appointments. If 24 hour notice is not given, you will be billed $30.00 for the session. If you have any questions about our Financial Policy you may direct them to Kendra, the Financial Coordinator. I have read the Financial Policy. I understand and agree to this Financial Policy. I authorize Linda Berry, DC or Kathleen Dvorak, DC to provide care for the examination and treatment of my case. I am ultimately responsible for all charges incurred, including any collection efforts or court fees. I hereby consent to any statements stated above, that apply to my situation. Copies of these statements are as legal and binding as the original. Signature/Date: Consent to Treat a Minor I hereby authorize the doctor to treat my son or daughter. Name of child: Name of Parent/Guardian: Date:

4 Complete Chiropractic & Bodywork Therapies 2020 Hogback Rd. Suite 7 Ann Arbor, MI Electronic Health Records Intake Form In compliance with requirements for the government EHR incentive program First Name: Last Name: Preferred method of communication for patient reminders (Circle one): / Phone / Mail DOB: / / Gender (Circle one): Male / Female Preferred Language: Smoking Status (Circle one): Every Day Smoker / Occasional Smoker / Former Smoker / Never Smoked CMS requires providers to report both race and ethnicity Race (Circle one): American Indian or Alaska Native / Asian / Black or African American / White (Caucasian) Native Hawaiian or Pacific Islander / Other / I Decline to Answer Ethnicity (Circle one): Hispanic or Latino / Not Hispanic or Latino / I Decline to Answer Are you currently taking any medications? If necessary, use back of form for additional entries or provide a separate sheet of your medications. (Please include regularly used over the counter medications) Medication Name Dosage and Frequency (i.e. 5mg once a day, etc.) Do you have any medication allergies? Medication Name Reaction Onset Date Additional Comments I choose to decline receipt of my clinical summary after every visit (These summaries are often blank as a result of the nature and frequency of chiropractic care.) Patient Signature: Date: For office use only Height: Weight: Blood Pressure: /

5 Complete Chiropractic & Bodywork Therapies 2020 Hogback Rd. Suite 7 Ann Arbor, MI (734) NOTICE OF PRIVACY PRACTICES Per HIPAA REGULATIONS Consent for Purposes of Treatment, Payment and Healthcare Operations THIS NOTICE DESCRIBES HOW MEDICAL/PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. I acknowledge that Complete Chiropractic & Bodywork Therapies Notice of Privacy Practices has been provided to me. I understand I have the right to review Complete Chiropractic & Bodywork Therapies Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of bills or in the performances of healthcare operations at Complete Chiropractic & Bodywork Therapies. The Notice of Privacy Practices is also provided on request at the main administration desk. This notice of Privacy Practices also describes my rights and Complete Chiropractic & Bodywork Therapies duties with respect to my protected health information. Complete Chiropractic & Bodywork Therapies reserves the right to change the Privacy Practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of Privacy Practices by calling the office and requesting a revised copy to be sent via mail or may request a copy at the time of my next scheduled appointment. Signature of Patient or Patient Representative Date Name of Patient or Patient Representative Description of Patient Representative s Authority Staff Witness Date

6 COMPLETE CHIROPRACTIC & BODYWORK THERAPIES PATIENT/CLIENT UPDATE FORM Date Referral Source Name Last First Middle Name I prefer to be called Address City State Zip Phone ( ) ( ) ( ) Home Work Cell/Pager Social Security# Male Female Occupation Employer Date of Birth Age Marital Status: S M W D Partner Emergency Contact Name Phone # Relationship The best phone number to use to contact me or leave a message is ( ).

7 COMPLETE CHIROPRACTIC & BODYWORK THERAPIES PATIENT/CLIENT COMPLAINT/SYMPTOM FORM Date: Name: Height Weight Numbness = = = Dull Ache OOO Burning XXX Sharp/Shooting / / / Pins/Needles Other ^ ^ ^ Please state your chief complaint: How long have you had the symptoms? How did the condition begin? How long did the symptoms last? What makes it worse? What makes it better? How would you describe your pain on a scale of 1 to 10? Circle or write down for each complaint: (0 is none 10 is severe)

8 Name: Date: Page 2 Previous treatment for this complaint (include any doctors names, dates treated, test results, or home remedies: (If you need more room; please write on back of sheet) X-rays, MRI s or CT s Where Taken Date Surgery Past Surgical History Year Reason Hospitalizations (other than surgery) Year Accident/Injury Accidents/Injuries Year Current medications/supplements Known allergies to medications/supplements Exercise, type and frequency: Describe your typical diet for Breakfast: Lunch: Dinner: How much of the following do you consume daily? Water: Milk: Soda: Coffee Cigarettes: Sweets: Alcohol: Tea Abdominal gas frequently? #of bowel movements daily? List any recent travel: Age of mattress: Regular: Waterbed Fouton: Sleep Position Do you like your job? How do you relieve stress? Spiritual/Religious affiliation/meditation/prayer List hobbies: With whom do you live? Estimate the stress in your life: None Mild Moderate Great Date of last physical exam? Have you ever had a professional massage, Polarity Therapy or craniosacral therapy? Are you currently in psychotherapy?

9 Name Date Page 3 Please CHECK conditions that apply and CIRCLE to specify further as necessary: Past Current SPECIFY Abdominal Allergies Anxiety Arthritis, osteo or rheumatoid Asthma Bleeding Disorder Blood Clots Blood Pressure high or low Cancer Chest Pain Chicken Pox/Measles/Mononucleosis Cough Dental/TMJ Depression Diabetes Digestive Disorder Dizziness/Fainting spells Ear Disorders/Hearing loss Eye Disorders Fibromyalgia/Chronic Fatigue Genetic Disease Gout Headaches/Migraines Heart Disorder Hepatitis Hernia Kidney Disorder Leg cramps Low blood sugar Lung Disorder Lupus Malaria Nausea/vomiting Nose problems/smell Polio, Rheumatic Fever, Scarlet Fever Seizures Sinus Problems Skin Disease Spinal problems Stroke Sudden weight loss/gain Thyroid Disease Ulcers Varicose Veins Venereal Disease

10 Name Date Page 4 Women Only Men Only Past Current Problems with Breasts Past Current Prostate Problems Vaginal Itch/Discharge Impotence Painful Intercourse Swollen or Painful Testicle Take Birth Control Pills Discharge Irregular Cycles/Bleeding Hot Flashes Difficulty Conceiving Age of First Period # of Pregnancies # of Miscarriages # of Abortions Passed Menopause at Age Date/Onset of last period: # of Days between cycles: Family History: State Health Problems or Relationship Age, if Living Age, at Death Cause of Death Father Mother Brothers Sisters Grandfather Grandfather Grandmother Grandmother