Dr. Jeff Eidsvig, DC,ART,TPI-CGFI 3060 Communications Parkway, Suite #104 Plano, Texas 75093

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1 Dr. Jeff Eidsvig, DC,ART,TPI-CGFI 3060 Communications Parkway, Suite #104 Plano, Texas New Patient Information/ Change of Information Date: New PT: Info Change: Patient Name: Age: Date of Birth: Gender: Male Female Ethnicity: SS# Address: Address: City/State/Zip: Home Phone: Cell Phone: Work Phone: Emergency Contact: Contact Number: Referred By: Internet Search (Search Engine): Primary Care Physician: Phone: Relationship Status: Married Single Divorced Widowed Patient Insurance Information Policy Holders Name: Policy Holders Date of Birth : Relationship to policy Holder: Self Spouse Child Primary Insurance Company: Employer: Insurance Type: PPO POS HMO 3rd Party/PIP (Auto) Subscriber ID: Group Number: Policy# Secondary Insurance Company: Policy# Group# Relationship To Policy Holder: Self Spouse Child If Auto Accident, Please Provide All Info: Attorney Information: Have you engaged in services of an attorney in connection with your present illness? Yes No If Yes, Name of Attorney: Phone# Authorization To Release Information: I hereby authorize the above named agency to release any 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,DC,PLLC and authorize payment directly to Jeff Eidsvig,DC,PLLC for services rendered. I accept responsibility for payment of any charges not paid or accepted by my insurance carrier. Signature of Patient/Legal Guardian: Date:

2 Treatment Consent/HIPPA Form: First Name: Last Name: I wish to be contacted in the following manner? (check all that apply): Home Telephone: Cell Phone: Address: Signature of Patient/LegalGuardian: Date: Insurance Authorization: I hereby authorize the release of medical or other information to my insurance company concerning charges/treatments provided to me by the doctor(s) listed. Transmittal by fax is authorized, I hereby assign benefits and I understand the payment is due as services are provided, including my deductible, copayment, 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 that the charges are my responsibility and payable immediately. Additionally, I understand that I am responsible for providing the referral form my primary care physician. In the event that such a referral had not been provided to the doctor(s) at Willow Bend Sports & Spine Center that I agree to pay for the service 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 necessary treatment for Chiropractic/Medical evaluation and heath care for the above mentioned patient. I understand that primary Chiropractic/Medical care is the responsibility of the doctor(s) at Willow Bend Sports & Spine Center and their staff. Patient Privacy Practices: I understand that I have rights regarding my protected health Information. These rights are 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 Willow Bend Sports & Spine Center Notice of Privacy Practices, which contains a complete description of the uses and disclosures of my protected health information. I understand that the Notice of Privacy Practices information serves as: -A basis for planning my care and treatment. -A means of communicating amongst the many health care professionals who contribute to my care. -A source of information for applying my diagnosis and surgical information to my bill. -A means by which a third-party payer can verify that services billed were actually provided. -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 that my personal health information will be used in treatment, payment and operations, including those activities which are performed in order to improve the quality of care. I acknowledge my receipt of the information. I give authorization for the release of Medical Records/Privacy Information to the following. I authorize my medical information to be discussed/disclosed to: Patient: Phone: Family Member: Phone: Printed Name Of Patient/Legal Guardian: Date: Signature of Patient/Legal Guardian: Date:

3 Patient History: Patient Medications: (Please Include Vitamins, Herbs, or Supplements) Past Medical Conditions/Hospitalizations/Surgeries: Patient Allergies: (Please List All Food and Med Allergies) Family History: (List Any Medical Conditions) Father: Mother: Brother(s): Sister(s): Grandmother(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 a MRI/ X-ray/CT Scan/Bone Scan for your condition(s) within the past year? Yes No If Yes, Please indicate which imaging and when?_ Social History: Patient Occupation (Describe Environment): Alcohol: No Yes If yes, I have drink(s) per day or drinks per month. Tobacco: No Yes If yes, I smoke approximately Pack(s) a day or Years. Illegal Drugs: No Yes If yes, what substance: Work History: Employed Unemployed Retired Homemaker Student Other Relationship Status: Married Single Divorced Widowed Signature of Patient/Legal Guardian: Date:

4 Insurance/Financial Info and Policies: First Name: Last Name: Financial Policies: Jeff Eidsvig, DC,PLLC appreciates your confidence in choosing us to provide for your health care needs. Our services imply a financial responsibility on your part and obligation to ensure payment to full of our fees. We would like to share our financial policies with you since a clear understanding of our financial policies is so important component of our professional relationship. Methods Of Payment: We will bill your insurance provider as a courtesy to you with a copy of your current insurance card, which must be presented at each visit or be kept on file and up to date. If you do not have your insurance card, payment is due at the time of service. For your convenience, we accept cash, check, Visa, Mastercard, American Express, and debit cards. Please note there is a $35 charge for returned checks by the bank due to insufficient funds. Insurance Participation: Jeff Eidsvig,DC,PLLC participates with many HMO s, PPO, and POS plans, which means we accept assignment of benefits. If payment is not received from your insurance carrier with our contract limits, any balances will be your responsibility. If we do not have a contract with your insurance carrier, you are responsible for payment in full and considered to be self pay. Payment is due at the time of service and we will mail you a courtesy claim with 7-14 days. Insurance Plans: As a component of the parameters of our contracts, we collect co-payments for every visit. In addition, we collect co-insurance, deductibles, and past due balances at the time of your services. You will be rescheduled if payment is not received at the time of service. If you are insured through a HMO, a referral is required from your primary care physician. if we do not receive the referral, we will require payment at the time of service. Contracted Insurance Companies and Additional Fees: Dr Jeff Eidsvig, DC,PLLC is contracted IN NETWORK with Blue Cross Blue Shield, Cigna, Aetna, United Heath Care, First Health, Multiplan, PHCS, Vista, Heath Smart, and others not mentioned. However, Jeff Eidsvig,DC,PLLC does perform procedures that are Not Covered by most insurance carriers. Upon completion of these procedures, i will be responsible for all out of pocket expenses in signing this document. I fully understand that I am aware of the above, and will be responsible for all outstanding balances that are not covered by the insurance carriers. Procedures NOT Covered By Insurance Carriers: Hyperbaric Oxygen Therapy: 30 min = $ min = $ min = $ Biocorrect Orthotics: $ plus shipping costs We are committed to provide the best treatment possible for our patients and we charge what is usual and customary for our area. If we do not have a contract with your insurance company, you are responsible for payment in full regardless of any insurance companies arbitrary determination of rates. Co-payments, coinsurance, and deductibles, or un paid balances are due at the time of service or possible use of a collection agency will be used. I have read the financial policies of Jeff Eidsvig,DC,PLLC. I understand that it is my responsibility to provide current insurance information at each visit, as required by my insurance carrier. I will be responsible for ALL OUTSTANDING BALANCES that are not covered by my insurance carrier. Signature of Patient/Legal Guardian:_Date:!

5 Office Policies: First Name: Last Name: 20 Minute Late Policy: Patient that show up 20 minutes late to any appointment will be asked to reschedule to another date and time. No Show Policy: Patients that schedule appointments but fail to show up are documented as No Show. The patient will be assessed a $50.00 No Show Fee and will be responsible for all payment of fees. Walk In Appointments: Willow Bend Sports & Spine Center is an appointment only office. Examination by a doctor cannot be guaranteed if you present to the office without an appointment. Payment: All payments are expected at the time of service. Because of high cost of billing, patients unable to make payments at the time of service will be rescheduled and required to submit payment before another appointment is made. Accepted methods of payment include cash, check, credit cards, and debit cards. Patients are responsible for their remaining balances, and are expected to pay within 4 submitted bills, or their balance will be sent to a collections agency. Patient Termination Policy: Although it is an infrequent occurrence, a patient may be terminated from the office. Patient termination is at the discretion of the patientʼs doctor/staff. Common reasons for termination include, but are not limited to, use of foul language, chronic non-compliance with recommended treatment, and abusive behavior of staff, doctors, visitors, or other patients. Form Completion: Please be aware that we need 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 and any additional pages will be a $.75 a page. I an abstract is sent to a continuing care provider, there is no charge. An authorization for release of information must be signed and submitted before any requests for records will be processed. Signature of Patient/Legal Guardian: Date: