SCHOOL-AGE CHILD HISTORY

Transcription

1 SCHOOL-AGE CHILD HISTORY (6 years and older) Name Date Reason for today s visit When did this problem first occur? Have you ever had this problem before? 0 0 Have you been treated for this problem before? 0 0 Doctor s name Have you previously been to a chiropractor? 0 0 ABOUT YOUR LIFESTYLE The following questions are designed to help the doctor provide the best possible spinal care for your child. What grade are you in at school: How do you carry your school books?: How heavy is your school book bag? What sports do you play? What hobbies do you have? How many hours each day do you watch TV/play video games/use the computer? On average how many hours of sleep do you get each night? Are there any smokers in your family? 0 0 Do you feel stressed out? 0 0 Do you have trouble reading the board in class? 0 0 Do you ever have blurred vision? 0 0 Do you wear glasses or contact lenses? 0 0 ABOUT YOUR HEALTH In the past have you had any of the following: Back or neck pain? 0 0 Pains in the legs or arms? 0 0 Headaches? 0 0 Asthma? 0 0 Allergies? 0 0 Earaches? 0 0 Falls from a bike, skateboard, scooter, etc? 0 0 Do you ever have a problem with bedwetting? 0 0 Have you ever been in a motor vehicle accident? 0 0 Have you ever had any broken bones? 0 0 Have you ever had any surgeries? 0 0 Are you presently taking any medications? 0 0

2 Do you have any other health problems? 0 0 PEDIATRIC NEW PATIENT INFORMATION Today s Date: PATIENT INFORMATION Child s Name: M/F Date of Birth: Child s Nickname: FAMILY INFORMATION Mother s Name: Mother s DOB: Address: City State Zip Home Phone: Cell: Work: Father s Name: Father s DOB: Address (If different than Mother s) City State Zip Home Phone: Cell: Work: INSURANCE INFORMATION Primary Insurance: Name of Insured: Date of birth of insured: Secondary Insurance: Name of Insured: Date of birth of insured: CONSENT TO TREAT Being the parent or legal guardian of this child, I hereby authorize this office and its doctors to examine and administer care to my son/daughter named above as the examining/treating doctor deems necessary. I understand and agree that I am personally responsible for payment of all fees charged by this office for such care regardless of what my insurance company covers. I hereby authorize Perreault Chiropractic to seek payment and authorize/assign payment directly to them from my insurance company. PARENT GUARDIAN SIGNATURE:

3 Consent to the Use and Disclosure of Health Informaton for treatment, payment, or healthcare operatons. I understand that as part of my healthcare, Perreault Chiropractc & Acupuncture originates and maintains health records describing my health history, symptoms, examinaton and test results, diagnoses treatment, and any future plans for care or treatment. I understand that this informaton serves as: A basis for planning my care and treatment. A means of communicaton among the many healthcare professionals who contribute to my care. A source of informaton for applying my diagnosis and surgical informaton to my bill. A means by which a third-party payer can verify that services billed were actually provided. A tool for routne healthcare operatons such as assessing quality and reviewing the competence of healthcare professionals. I understand that a Notce of Privacy Practces is available at my request which provides a more complete descripton of informaton uses and disclosures. I understand that I have the right to review the notce prior to signing this consent. I understand that Perreault Chiropractc & Acupuncture reserves the right to change their notce and practces and prior to implementaton will mail a copy of any revised notce to the address Iave provided. I understand that I have the right to objeect to the use of my health informaton for directory purposes. I understand that I have the right to request restrictons as to how my health informaton may be used or disclosed to carry out treatment, payment, or healthcare operatons and that Perreault Chiropractc is not required to agree to the restrictons requested. I understand that I may revoke this consent in writng, except to the extent that Perreault Chiropractc & Acupuncture has already taken acton in reliance thereon. Signature: Date:

4 Patent Financial Responsi ility PolicyAuuthoriaaton & ussinnment of eeneits General The patentas insurance policy is a contract between the patent and his or her insurance company. However, all charnes renardless of the insurance coverane are the patentts responsi ility and the patent is ultmately responsible for any unpaid balances. As a courtesy to our patents, PC & A bills the patentsa insurance and makes every effort to ensure that claims are promptly and correctly processed. PC & A also bills patentsa secondary insurance when patents provide complete insurance informaton. Patent co-pays are expected at the tme of service, and any remaining payment is due within g0 days of receiving the frst bill from PC & A. We accept cash, checks, money orders, debit cards and credit cards (Visa, Master Card, Discover and American Express). If you canat pay your balance within g0 days, please contact our ofce and we will work with you to fnd a monthly payment amount that will work with your fnancial needs. If no insurance informaton is provided, or the correct informaton is not provided within the allowed amount of tme set by the insurance company, the patent will be fully responsible for charges incurred. Past Due ealances A past due balance is any amount owed afer the insurance company has paid its porton, but where PC &A has not received the full patent balance within ninety (90) days. Patients who hoavie a prievi us c lliect n agiency balancie and wisho t riecieivie siervicies arie riequiried t pay any niew choargies at thoie tiie o sierviciee. I hereby authorize Perreault Chiropractc & Acupuncture to release to my insurance company informaton necessary for them to process my claims for care. I also assign insurance benefts to Perreault Chiropractc & Acupuncture as may be allowed by my insurance company. I further understand that I am fully responsible for all the charges incurred at Perreault Chiropractc & Acupuncture, regardless of my insurance coverage. Please note: We will do all we can to ensure your care is covered by your insurance carrier. However, benefts quoted to us are not a guarantee of payment but a general outline of your coverage. If a problem arises, we will appraise you as soon as possible and will expect you to call your insurance carrier to clear up any problems. Please keep in mind your contract is between you and your insurance carrier. We do not have any legal rights to your insurance contract you do. Please be aware that many insurance carriers can take up to g months or more to process a claim. Patent Name: Signature: Date:

5 Patient Messaging Consent By supplying my home phone number, mobile phone number, address, and any other personal contact information, I authorize my health care provider to employ a third-party automated outreach and messaging system to use my personal information, the name of my care provider, the time and place of my scheduled appointment(s), and other limited information, for the purpose of notifying me of an upcoming appointment, a missed appointment, balances due, or other communications. I also authorize my healthcare provider to disclose to third parties, who may intercept these messages, limited protected health information (PHI) regarding my healthcare events. I consent to receiving multiple messages per day from the automated outreach and messaging system, when necessary. Patent Name Date Patent Signature Cell number: Please send me text reminders for my upcoming appointments cell phone provider: Circle how far in advance you would like the reminders to be sent 15 mins g0 mins 1 hr 2 hrs 4 hrs 1 day 2 days 1 week