Marital Status Patient s Last Name First Initial Date of Birth S M D W. Home Phone Work Phone Mobile Phone . Address City State Zip

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Rafe Singleton
6 years ago
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1 PATIENT INFORMATION Marital Status Patient s Last Name First Initial Date of Birth S M D W Home Phone Work Phone Mobile Phone Address City State Zip Occupation Employer Employer Phone Employer Address City State Zip Primary Care Physician PCP Phone Physician Therapist Friend Family Other Referral Source Prior Chiropractic Treatment? YES NO Physical Therapy? YES NO If YES, what for? WORK OR AUTO ACCIDENT INFORMATION (Please complete if applicable) Is the reason for your visit work or auto accident related? YES NO If YES, have you or do you plan to file a worker s compensation or auto claim / legal action? YES NO PATIENT SIGNATURE DATE AUTHORIZATION FOR MINOR PATIENTS (Please complete if applicable) I hereby request and authorize Sports Medicine Solutions, S.C physicians to perform evaluations and diagnostic tests, and render treatments to my MINOR SON / DAUGHTER. This authorization also extends to all other providers and office staff members. As of this date, I have the legal right to select and authorize health care services for the minor child named above. If my authority to select and authorize this care should be revoked or modified in any way, I will notify this office. NAME OF MINOR PATIENT DATE OF BIRTH NAME OF PARENT / GUARDIAN (print) SIGNATURE OF PARENT / GUARDIAN DATE RELATIONSHIP TO PATIENT WITNESS!"#$%&$'())$*+,&$-./0,$123$$4,)056708$9:$;2##<$$$$$=$;>2&#""?32;2$$$$$$@$;>2&#""&32;1$

2 MEDICAL HISTORY PATIENT NAME DATE What problem/issue brings you here today? How and when did it start? What makes it worse? What makes it better? What are your goals for care? What diagnostic tests have you had for this problem? X-ray MRI CT scan EMG Bone scan What treatments have you had? Massage Injections Physical Therapy Medications Chiropractic Please make a mark on the line below to indicate the level of discomfort you have today. No Pain Worst Pain Ever Please describe what the pain feels like: Dull, Achy, Burning, Stabbing, Numbness, Tingling, Pulling, Cramping, Tightness Please describe the time course of your pain: Constant, Comes and goes, Getting worse, Getting better, Staying about the same Current Medications: Please include ALL medications including Prescription, Over-the-Counter, Supplements, Vitamins, Herbs Please mark the locations of your pain or discomfort Medical/Surgical History: Please list ALL Surgeries and Medical Conditions, for example: Diabetes, Cancer, High blood pressure, Heart attack, Pacemaker, Arthritis, Fractures, Accidents, Osteoporosis, etc Allergies: Medications, Environmental, Foods, Other Family History: Cancer, Heart disease, Diabetes, Stroke, Arthritis, Osteoporosis, Other? What do you do for exercise?

3 MEDICAL HISTORY PATIENT NAME DATE Occupation: Physical requirements: Prolonged Sitting Prolonged Standing Lifting Travel Driving Computer Phone Childcare Employment status: Full-time Part-time Light Duty Off Duty due to injury Full-time Parent Not working Retired Night pain, fevers, unintentional weight change? Yes No Review of Systems (ROS) comments: Vision change, blurred or double vision? Yes No Headaches? Yes No Chest pain, palpitations? Yes No Shortness of breath, wheezing or cough after exercise? Yes No Nausea, vomiting, bloating, or diarrhea? Yes No Loss of control of urine, urinary frequency or urgency? Yes No Skin problems, rashes or psoriasis? Yes No Dizziness, weakness, numbness, tingling? Yes No Depressed mood, sleep problems, anxiety? Yes No Joint swelling or muscle pain? Yes No Smoking History: Current Quit Never Pack-years: Number of alcoholic beverages per week? Number of caffeinated beverages per day?! Are you pregnant, trying to get pregnant or breastfeeding? Yes No! Last menstrual period date: Periods regular? Yes No! Number of Children? Cesarean? Yes No Please make a mark on the line below to rate your daily stress level. Perfect Terrible Please make a mark on the line below to rate your stress management ability. Perfect Terrible Please make a mark on the line below to rate your dietary habits. Perfect Terrible Patient Signature: Dr. Initials Date:

4 INSURANCE INFORMATION Please select the section that applies to your case and fill out the requested information! SELF PAY Our office accepts cash, checks, Visa, MasterCard, and Discover! PRIVATE INSURANCE Primary Policy or Medicare Insurance Company Address City, State, Zip Policy Holder SSN and Date of Birth Policy / ID Number Group Number Insurance Co. Phone Secondary Insurance Policy (if applicable) Insurance Company Address City, State, Zip Policy Holder SSN and Date of Birth Policy / ID Number Group Number Insurance Co. Phone I certify that I (or my dependant) have insurance coverage as noted above and assign directly to Sports Medicine Solutions, S.C. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of this signature on all my insurance submissions. Print Name Responsible Party Signature Policy Holder Date of Birth Relationship Today s Date

5 FINANCIAL POLICY We are committed to providing you with the best possible services and would like to make you comfortable in your association with us. The following is a statement of our Financial Policy, which we require you to read and sign. Your cooperation and familiarity with this policy will help to control the costs of your health care. REGARDING ALL INSURANCE We cannot promise that an insurance company will pay for your care, even when it is preauthorized. As a courtesy, our office will inquire about your insurance benefits for services / treatments specific to our practice. Please understand that insurance carriers advise us that payment of benefits will not be determined until your claim is received and reviewed according to the specifics of your plan, and that a quote of benefits is not a guarantee of payment. Understand that you are financially responsible for any co-pays, deductibles, and remaining balances not covered by your plan. We strongly urge you to contact the insurance company to verify your benefits, as incorrect information is sometimes provided to us. We will submit bills to your insurance carrier as soon as we are able to confirm coverage for chiropractic services and have the proper, signed insurance forms, but will not become involved in disputes between the insured and the insurance company. Payment of non-covered and service balances, co-payments / deductibles is expected at the time of service. Our office accepts cash, checks, and some credit cards. NETWORKS We are in-network with Blue Cross Blue Shield PPO and out-of-network with all other insurance plans. As the insured, it is your responsibility to know and understand the benefits of your health insurance plan including differences between in and out of network coverage such as deductible and co-pay amounts, percent of coverage and any referrals that may be required. Co-payments are due and will be collected at time of service. MEDICARE Medicare pays for only a portion of chiropractic services and limits the number of reimbursable treatments per calendar year, based on your diagnosis and does not cover many of the services commonly rendered by this office. Please be advised of the following Medicare regulations and restrictions: Medicare will not pay for an initial examination, nor follow up or re-examinations. services will be the patient's responsibility and will not apply to the patient's deductible. Fees for these Reimbursable care is limited to spinal manipulation and does not include other therapies, services and goods that may be necessary during care, such as other manual therapies, exercise instruction or supplements / supplies. Reimbursable care is limited to spinal-related conditions. Medicare will not pay for an initial examination; therefore, this fee will be collected at the initial consultation. When the maximum number of treatments has been rendered, payment is expected at the time of service. Page 1 of 2

6 FINANCIAL POLICY SUPPLIES / SUPPLEMENTS All medical supplies or supplements must be paid for at the time of delivery. We do not bill your insurance company for these items, but will provide you with the necessary paperwork in order that you may file a claim with your own insurance company for consideration of reimbursement. WORKERS COMPENSATION & PERSONAL / AUTO INJURY If the reason for your visit is related to an active or pending worker s compensation or personal / auto injury claim or litigation, you must notify us prior to initiation of care or at any point during care that your case changes to one of these claim types. Workers Compensation and Personal Injury cases will be seen on a self-pay basis, meaning payment for services is due in full at the time of service. We do not submit for reimbursement for these cases, nor accept physician s liens, but we will furnish you the information you may need to bill for reimbursement. COLLECTIONS POLICY In the event that you do not meet your financial obligation for services provided in our office, we may send your account to a collection agency, typically after 90 days of non-payment. If this becomes necessary, any fees incurred will be your responsibility. You will be notified prior to sending your account to collections. If you are experiencing financial hardship or there are circumstances which prevent you from paying the full balance due, please contact our office so that we can work with you to find a solution. CANCELLATION / NO SHOW POLICY Patients canceling appointments with less than 24 hours notice or failing to show for a scheduled appointment may be charged a $30 fee for that appointment. NOTICE OF PRIVACY PRACTICES As required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPPA) this notice describes how health information about you (as a patient of this practice) may be used and disclosed and how you can get access to this information. A copy of this policy is available from your health care provider. REQUIRED SIGNATURE I (signed below) have read the above Financial Policy and I understand and agree to the Financial Policy. Additionally, my signature authorizes Assignment of Benefits to Sports Medicine Solutions, S.C. and the release of all information necessary to secure the payment of benefits. Signature (Patient or Responsible Party) / / Date Name (Please Print) Page 2 of 2

Registration Form. Gender: Male Last Name First Name Middle Initial Female. - - / / Social Security Number Date of Birth Age Occupation / Employer

Registration Form. Gender: Male Last Name First Name Middle Initial Female. - - / / Social Security Number Date of Birth Age Occupation / Employer Registration Form General Information Have you been treated by us before? Yes No Gender: Male Last Name First Name Middle Initial Female Social Security Number of Birth Age Occupation / Employer Street