PATIENT INFORMATION INTAKE F O R M BESSMER CHIROPRACTIC P. C.

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1 PATIENT INFORMATION INTAKE F O R M BESSMER CHIROPRACTIC P. C. Date today: _ PERSONAL INFORMATION Full Name: SS#: Address: City: State: Home Phone: Cell Phone: W o r k Phone: Birthdate: Age: Sex: DM Marital Status: Married Single Other: Employment Status: Employed -_ DF Zip: Height: Weight: Referred to this office by: Unemployed Employer: FT Student n PT Student Other Occupation: How w i l l your b i l l be covered? Personal Health Ins n Medicare Medicaid Auto Ins WorkComp Self-Pay Other:, C U R R E N T H E A L T H CONDITIONS What are your major complaints?: Any other complaints?: On a scale of o - i o, o - ne & lo-unbarable, how would you rate your pain? When d i d (you notice) this condition begin?: How d i d this condition begin?: Does anything make the pain better?: Does anything make the pain worse?: Have you seen other doctors for this condition?: I f yes, who?: What were the results?: Medications you're taking to treat THIS condition: Please list all other medications: Please list any allergies to any medications: Females: Are you currently pregnant?: Due date: PAST H E A L T H HISTORY Surgeries or operations: Major accidents of falls: Hospitalizations (other than noted above): Have you been treated for any health condition i n the last year?

2 ELECTRONIC H E A L T H RECORDS INTAKE FORM O M P I r AN{ K W i l l i R l Q l I R K M K M S I O R I l l i : (. O M R N M K M H I R IN( I \M Name: PR()(;RAM) Date of Birth: Gender: Male Female Height Weight Preferred Language: address: Preferred Method of communication for patient reminders: Q Smoking Status : D Every day Smoker (smoking start date: CD Former Smoker O (smoking start date: Q Phone Mail ) CD ) CD Never Smoked Occasional Smoker CMS requires providers to report b o t h race and ethnicity Race: CD American Indian or Alaska Native CD Asian CD Black or African American CD White Native Hawaiian or Pacific Islander CD Other Ethnicity: CD Hispanic or Latino CD Decline to Answer CD t Hispanic or Latino Are you currently taking any medications? NO CD YES I f yes, please hst below. Medication N a m e Do you have any medication allergies? CD Decline to Answer Dosage CD NO CD YES Frequency I f yes, please list below. Medication N a m e Reaction Family Medical History: Please record o n e diagnosis i n your family history and identify the affected. D i a g n o s i s (write b e l o w ) Father Example: L o w back pain I Mother S i b l i n g CCircle o n e ) C h i l d ( C i r c l e one) B r o t h e r Sister Son Daughter X I c h o o s e to d e c l i n e receipt of m y clinical s u m m a r y after every visit. ( T h e s e s u m m a r i e s a r e often b l a n k as a result of t h e n a t u r e a n d frequency of c h i r o p r a c t i c care.) Patient Signature: Date: V O L W I L L R L C L I \ AN L M A I L w m i A ( ( L S S I ( ) > ( ) L R M L D K V L R L ( O R D S I H R O I ( R N L W ( V I L D K A L R L C O R D S F O R I A I,! For Office U s e Only: Blood P r e s s u r e

3 ACKNOWLEDGEMENT O FRECEIPT O F PRIVACY PRACTICES K ( p a t i e n t ' s n a m e ) a c k n o w l e d g e that 1 can request a c o p y and agree to the N o t i c e o f P r i v a c y Practices o f Bessmer C h i r o p r a c t i c, P. C, w h i c h describes the p r a c t i c e ' s p o l i c i e s and procedures r e g a r d i n g the use and d i s c l o s u r e o f any o f m y Protected H e a l t h I n f o r m a t i o n created, r e c e i v e d o r m a i n t a i n e d b y the Practice. Patient Consent to Use and Disclose Health Information (Consent for Purposes of Treatment, Payment and Healthcare Operations) I consent t o Bessmer C h i r o p r a c t i c, P.C. (''the P r a c t i c e ' s " ) use a n d d i s c l o s u r e o f m y Protected H e a l t h I n f o r m a t i o n f o r the purpose o f p r o v i d i n g t r e a t m e n t t o me, f o r purposes r e l a t i n g t o the p a y m e n t o f services r e n d e r e d t o me, and f o r the Practice's general healthcare operations purposes. H e a l t h c a r e operations purposes shall i n c l u d e, b u t n o t be l i m i t e d t o, q u a l i t y assessment a c t i v i t i e s, c r e d e n t i a l i n g, business m a n a g e m e n t and other general o p e r a t i o n a c t i v i t i e s. 1 understand t h a t the Practice's d i a g n o s i s or t r e a t m e n t o f m e m a y be c o n d i t i o n e d u p o n m y consent as e v i d e n c e d b y m y signature on t h i s d o c u m e n t. F o r purposes o f t h i s Consent, ''Protected H e a l t h I n f o r m a t i o n ' ' means any i n f o r m a t i o n, i n c l u d i n g m y d e m o g r a p h i c i n f o r m a t i o n, created o r r e c e i v e d b y the Practice, that relates t o m y past, present or f u t u r e p h y s i c a l or m e n t a l h e a l t h or c o n d i t i o n, the p r o v i s i o n o f h e a l t h care t o m e, o r reasonable basis t o b e l i e v e t h e i n f o r m a t i o n can be used t o i d e n t i f y me. I u n d e r s t a n d I have the r i g h t t o request a r e s t r i c t i o n on the use and d i s c l o s u r e o f m y Protected H e a l t h h i f o n n a t i o n f o r the purposes o f t r e a t m e n t, p a y m e n t o r healthcare operations o f t h e Practice, but t h a t Practice is n o t r e q u i r e d t o agree t o these r e s t r i c t i o n s. H o w e v e r, i f the Practice agrees t o a r e s t r i c t i o n t h a t I request, the r e s t r i c t i o n is b i n d i n g o n the Practice. 1 understand I have the r i g h t t o r e v i e w the Practice's N o t i c e o f P r i v a c y Practices p r i o r t o s i g n i n g t h i s d o c u m e n t. The N o t i c e o f P r i v a c y Practices describes m y r i g h t s and the Practice's duties r e g a r d i n g the types o f uses a n d disclosures o f m y Protected H e a l t h I n f o r m a t i o n. I have the r i g h t t o r e v o k e t h i s consent, in w r i t i n g at any t i m e, except t o the extent that P h y s i c i a n o f the Practice has acted in reliance on t h i s consent. Signature o f Patient or Personal Representative Date ********************************** Bessmer Chiropractic has my permission to release personal health information to the following people fbr the purpose o f such things as: appointment reminders, follow-up calls, basic contact information, insurance updates and account balance statements and payments. Ihe following family members may be included on the same billing statement:

4 BESSMER CHIROPRACTIC, P. C. INFORMED CONSENT TO CHIROPRACTIC T R E A T M E N T I h e r e b y request a n d consent to the p e r f o r m a n c e of c h i r o p r a c t i c adjustments a n d other c h i r o p r a c t i c p r o c e d u r e s, i n c l u d i n g v a r i o u s m o d e s of p h y s i c a l t h e r a p y a n d diagnostic x - r a y s, on m e (or the patient n a m e s before, for w h o m I a m legally r e s p o n s i b l e for) by Doctor C h r i s t i a n B e s s m e r D. C., of B e s s m e r C h i r o p r a c t i c P. C. C h i r o p r a c t i c t r e a t m e n t involves the science, p h i l o s o p h y a n d art of locating a n d correcting s p i n a l m i s a l i g n m e n t s a n d as s u c h, is oriented t o w a r d i m p r o v e m e n t of s p i n a l function relative to range of motion, m u s c u l a r a n d neurological aspects. I u n d e r s t a n d that the c h i r o p r a c t o r will u s e h i s h a n d s or a m e c h a n i c a l device u p o n m y body to adjust a j o i n t, w h i c h m a y c a u s e a n audible "pop" or "click". I h a v e h a d a n opportunity to d i s c u s s w i t h Doctor C h r i s t i a n B e s s m e r D. C., t h e n a t u r e a n d p u r p o s e of c h i r o p r a c t i c adjustments s a n d other p r o c e d u r e s. I u n d e r s t a n d a n d I a m i n f o r m e d that, as in the practice of m e d i c i n e, in t h e p u r p o s e of c h i r o p r a c t i c there are s o m e r i s k s to treatment i n c l u d i n g, but not l i m i t e d to, fractures, d i s c injuries, strokes, dislocations a n d s p r a i n s. It is not r e a s o n a b l e to expect the doctor to be able to anticipate a n d explain all risks a n d c o m p l i c a t i o n s of a given p r o c e d u r e on a n y p a r t i c u l a r visit, a n d I w i s h to rely on the doctor to exercise j u d g m e n t d u r i n g the c o u r s e of t h e p r o c e d u r e w h i c h the doctor feels at the t i m e, b a s e d u p o n facts t h e n k n o w n, is in m y best interest. T h e risks of c o m p l i c a t i o n s d u e to c h i r o p r a c t i c treatment h a v e been d e s c r i b e d as "rare", about as often as c o m p l i c a t i o n s a r e s e e n from t h e t a k i n g of a single a s p i r i n tablet. O t h e r treatment options, w h i c h could be c o n s i d e r e d, m a y i n c l u d e t h e following: Over-the-counter 1. analgesics. T h e r i s k s of these m e d i c a t i o n s i n c l u d e irritation to the s t o m a c h, liver a n d k i d n e y s, a n d other side effects in a significant n u m b e r of cases. 2. Medical care. Typically, a n t i - i n f l a m m a t o r y drugs, t r a n q u i l i z e r s a n d analgesics. R i s k s of these drugs i n c l u d e a m u l t i t u d e of u n d e s i r a b l e side effects a n d patient d e p e n d e n c e i n significant n u m b e r of cases. 3. Hospitalization. I n conjunction w i t h m e d i c a l care, a d d s r i s k of exposure to v i r u l e n t c o m m u n i c a b l e disease i n a significant n u m b e r of cases. 4. Surgery-. I n conjunction w i t h m e d i c a l care, adds r i s k s of adverse reaction to a n e s t h e s i a, as well as a n extended convalescent p e r i o d i n a significant n u m b e r of cases. I h a v e read, or h a v e h a d r e a d to m e, the above consent, a n d by signing below I agree B e s s m e r C h i r o p r a c t i c P. C, procedures. I intend t h i s consent for to cover the entire c o u r s e of treatment for m y p r e s e n t condition a n d for a n y future c o n d i t i o n ( s ) for w h i c h I seek treatment. *Patient N a m e *Signature of Patient or Legal Representative (Parent, G u a r d i a n, Attorney) *Date

5 CONSENT F O R T R E A T M E N T O F A MINOR C H I L D I hereby authorize - Bessmer Chiropractic P.C. and designated employees and interns to diagnose and treat as described above, my son, daughter, or dependent: (minor's name). I hereby certify that I a m the parent or legal guardian of the above named minor. PRINTED NAME: SIGNED: DATE: ASSIGNMENT OF BENEFITS I hereby assign all medical and health care benefits, to include major medical benefits to which I am entitled including Medicare, Auto Insurance, Private Health Insurance, and any other plans to Bessmer Chiropractic, P.C. A copy or fax of this assignment is to be considered as effective and valid as the original. I understand that I am financially responsible for all charges whether paid by insurance or not I hereby authorize the release of any information necessary to secure payment. I certify that I have read and understand the above assignment of benefits. PRINTED NAME: SIGNED DATE:

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