PATIENT INFORMATION. Age: Street address: Primary Phone no.: City: State: ZIP Code: P.O. box: Occupation: Employer: Employer phone no.

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1 (Please Print) Today s date: PATIENT INFORMATION Patient s last name: First: Middle: Birth date: Age: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid Sex: M F Street address: Primary Phone no.: City: State: ZIP Code: P.O. box: Occupation: Employer: Employer phone no.: Name of primary care physician: Name of his/her facility: PCP phone no. (if possible): Chose clinic because/referred to clinic by: Dr. Insurance Plan Hospital Family Friend Close to home/work Online Search Other (please explain): INSURANCE INFORMATION (Please give your insurance card to the receptionist.) Person responsible for bill (if other): Birth date: Address (if different): Phone no.: / / Primary Subscriber s name (if other): Birth date: Phone no.: Patient s relationship to subscriber: / / Self Spouse Child Other IN CASE OF EMERGENCY Name of Emergency Contact: Relationship to patient: Phone no.: The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize [Name of Practice] or insurance company to release any information required to process my claims. Patient/Guardian signature Date 1

2 PATIENT HEALTH BACKGROUND What is your current height? What is your current weight? What is your occupation? Which of the following activities are involved? Heavy lifting Prolonged sitting Prolonged standing (please specify if a lot of walking is involved): Light labor Other: Have you ever had any additional major injuries since your last visit (e.g. fractures, herniated disk, sprain, concussion or a pinched nerve)? Have you been in a motor vehicle accident since your last visit? Please list dates, injuries and any long-term effects: Please list the region and reason for any X-rays, CAT scans, MRI s, ultrasounds etc. you have had in the last year: Please list any medications you are currently taking: (Women): Are you pregnant? Do you smoke? If yes, how much? Do you drink? If yes, how much? Do you have a special diet or take any nutritional supplements? List the exercise do you do in a typical week? This includes regular walks over 20 minutes. CURRENT COMPLAINT / ISSUE Chief complaint(s). Please be as specific as possible include where the pain is, when the symptoms started and, if you know, why/how. Is this due to a motor vehicle accident or worker s compensation injury? If yes, please let the receptionist know. Is the problem getting progressively worse? Please rate your pain level on a scale of 0 (no pain) to 10 (worst pain imaginable) when you are: At rest: 2

3 Moving: On average: When it s at its worst: Is the pain constant, or does it come and go? Please be as detailed as possible. Which activities does your pain make difficult to perform: Sitting Bending Standing Lying down Walking Other: Are you currently experiencing any of the following symptoms? Trouble with eyes/vision Pain / tightness in jaw Chest pain or heaviness with activity Skin rash / dermatitis / eczema Shortness of breath or prone to coughing Abdominal / stomach pain Recent change in bowel movements/bladder functions Excessive thirst / urination Trouble walking or loss of balance Nausea / loss of appetite Trouble with hearing Increased pain with rest / at night Trouble swallowing or chewing Severe headaches Heartburn Trouble sleeping Lost or gained 10lbs in the past year without trying Any joint swelling / stiffness Pain / swelling in feet Frequent dizziness / lightheadedness Easily tired Fallen to the ground in the past year If you have already had any treatment for this condition, please list the doctor(s), the facility, and the date(s) (as best you can): 3

4 CONSENT TO TREAT Chiropractic examination and therapeutic procedures (including spinal and/or extremity adjustments, heat/cold application, mechanical traction and manual muscle therapy), exercises & therapeutic massage (including deep tissue manipulation, traction of extremities and spine, hydrotherapy, reflexology, and manual lymphatic drainage) are considered safe and effective methods of care. However, any procedure intended to help may have complications. While the chances of experiencing complications are small, it is the practice of the chiropractor and/or his massage therapists to inform his patients about them, depending on who performs the procedures to the patient. These complications include, but are not limited to: soreness, inflammation, soft tissue injury, dizziness, burns and temporary worsening of symptoms. More serious complications are extremely rare. Additional information on side effects and complications is available upon request. I have read and understand the above statements regarding treatment side effects. I also understand that there is no guarantee or warranty for a specific cure or result. Patient/Guardian Signature: RELEASE OF INFORMATION I give permission to my provider and staff to release information, verbal and written, contained in my medical record, and other related information, to my insurance company, case manager, attorney, and related healthcare provider. I understand that all release of information is contingent upon prior approval in writing by myself. I have read and understood the above release. CANCELLATION POLICY I understand that twenty-four (24) hours notice is not only appreciated, but also required when canceling an appointment. I also understand that I will be directly charged (insurance does not cover missed appointments) for missed appointments that I do not cancel according to the twenty-four hour policy, and I agree to pay for as such. Charges for Dr. Li are: $30 for a 15-minute appointment, $50 for a 30-minute appointment, and $90 for a 60-minute appointment. Charges for Massage Therapy are $50 per missed appointment. I have read and understood the above. ACCOUNT POLICY 1. Payment is expected at the time of service. 2. As a service to you, your insurance company will be billed. If Mobility Plus (Dr. Michael Li and/or the massage therapists) can document your coverage, they will ask you to pay at the time of each office visit, the amount your insurance company will not pay. This may be a deductible, percentage fee or co-pay. 3. You will be expected to pay for all non-covered services, supplements or supplies at the time they are presented to you. 4. If for some reason, the information obtained by the insurance company is inaccurate, or services that were thought to be covered are not paid for, you may be informed of a balance due. Information from insurance companies is not a guarantee of benefits. You are responsible for all charges incurred while under care in this office. 5. If you have a personal injury (motor vehicle accident) claim, we will bill your insurance company. If the insurance company does not cover 100% of your bill, you will be responsible for the difference. It is expected that if an attorney has been assigned to your case, a lien will be signed for assignment of benefits for services. I authorize payment directly to Mobility Plus Sports Rehab (Dr. Michael Li) for services rendered to me. I understand and agree that health and accident policies are a contract between my insurance company and me. I also understand that if my insurance provider refuses payment, my services are not billable to insurance or my deductible has not been met, I am directly and fully responsible to said provider for all bills submitted by them for services rendered to me. I understand that all co-payments (and applicable supply charges) are due at time of service. I also understand that verification of benefits prior to services rendered is my responsibility and some services may not be covered by my individual insurance policy. Payment for these services are my responsibility. I have read and understood the above. 4

5 CONSENT Please initial each item below: I authorize the providers at Mobility Plus Sports Rehab to provide healthcare services to me. I understand and agree that regardless of insurance coverage, I am liable for any charges incurred as a result of services rendered to me by the providers of Mobility Plus. If my account is assigned to an attorney for collection and/or suit due to delinquency, the prevailing party shall be entitled to Attorney s fees and cost for collection. I authorize any insurer to make payment for services rendered by Mobility Plus Sports Rehab, directly to Mobility Plus Sports Rehab, at th Avenue, Suite 832, Seattle, WA I authorize the release of records to third parties requiring records for determination of financial liability. By signing this paper, I affirm under penalty of law that I have given true and complete ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES To save paper, we do not attach copies of our Privacy Practices to this form. The receptionist would be happy to provide you with a copy, or one can be found on our website at The Notice of Privacy Practices tells you how we may use and share your health records. Please read it. We will use and share your health records to treat you and to bill for the services we provide. We will use and share your health records to enhance intra office communication amongst staff. We will use and share you health records as required by law. All the ways we may use and share your health records are explained in more detail in the Notice of Privacy Practices. You have the rights with respect to your health records: 1. You have the right to look at and receive a copy of your health records. 2. You have the right to receive a list of whom we have given your health records to. 3. You have the right to ask for us to correct a mistake in your health records. 4. You have the right to ask that we not sue or share your health records. 5. You have the right to ask us to change the way we contact you. All of these rights are explained in more detail in the Notice of Privacy Practices. I have received a copy of Mobility Plus Sports Rehab Notice of Privacy Practices. CONSENT: I consent to the use and sharing of my health records for treatment, payment, and operation purposes as described in the Notice of Privacy Practices. I know that if I do not consent, you cannot provide services to me. Washington law requires that we advise you that the information authorized for disclosure may include information which may be considered a communicable or venereal disease, including, but not limited to, Hepatitis, Syphilis, Gonorrhea, Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome (AIDS). It may also include mental health or other sensitive information. 5