COLLINS CHIROPRACTIC CLINIC

Transcription

1 Welcome to Collins Chiropractic We are pleased that you have chosen our practice for your chiropractic needs. Caring for you is our privilege. Enclosed are several informational items that will acquaint you with the practice and provide useful information about your future care. We encourage you to take a few minutes to look through the information provided. If you have any questions or concerns, please feel free to call our office. Additionally, our website has been designed to assist patients with frequently asked questions and directions to our clinic. Visit us at In preparation for your appointment, please: 1. Complete the enclosed new patient forms 2. Bring the following to your initial appointment: Driver s license or Photo ID Current insurance cards Current medication list Available copies of all diagnostic testing such as x-rays and/or MRI s Please plan on arriving to your initial appointment at least fifteen (15) minutes early, in order to complete the patient registration process. Again, thank you for choosing Collins Chiropractic. We look forward to providing you with superior care and service. Please contact our office at (734) if you have any further questions prior to your appointment. Chiropractically Yours, Dr. Daniel Collins & Staff

2 Date: File Number First Name Middle Last Name Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages Home Phone ( ) - Work Phone ( ) - Cell Phone ( ) - Date of Birth / / Sex: Male Female Social Security Number: - - Marital Status: Single Married Other Employment Status: Employed Unemployed FT Student PT Student Other Employer Your Occupation Spouse Information First Name Middle Initial Last Name Home Phone ( ) - Work Phone ( ) - Spouse Date of Birth / / Emergency Contact Contact Name Relationship to Patient Contact Home Phone ( ) - Cell Phone ( ) - How did you hear about our office? Doctor s Signature (Daniel L. Collins,D.C.)

3 Medical Conditions: (Circle all that apply to you) Arthritis Cancer Diabetes Heart Disease Hypertension Psychiatric Illness Skin Disorder Stroke Fibromyalgia Asthma Osteoporosis Other Surgeries: (Circle all that apply to you) Appendectomy Cardiovascular procedure Cervical spine Hysterectomy Joint Replacement Prostate Lumbar spine Gall Bladder Brain Shoulder Thoracic spine Knee Carpal Tunnel Gastro-intestinal Uro-genital Hernia Breast Augmentation Other Allergies: (Circle all that apply to you) Mold Seasonal Milk or Lactose Animal Chemical Sulfites Wheat/Glutens Other Social History: (Circle all that apply to you) Caffeine use: occasional often never Drink Alcohol: occasional often never Exercise: occasional often never Drink Water: <64 oz/day >64 oz/day never Cigarettes: <1 pack/day >1 pack/day never Sleep: <8 hours/night >=8 hours/night Insomnia Other Family History: (Circle all that apply) Arthritis: Parent Sibling Cancer: Parent Sibling Diabetes: Parent Sibling Heart Disease Parent Sibling Hypertension Parent Sibling Stroke Parent Sibling Thyroid Parent Sibling Other Occupational Activities: (Circle one that best describes your job description) Administration Business Owner Clerical/Secretary Computer User Heavy Equipment operator Daycare/Childcare Construction Health Care Food Service Industry Medium Manual Labor Manufacturing Housekeeper Heavy Manual Labor Light Manual Labor Executive/Legal Other Please list all current medications being taken Doctor s Signature (Daniel L. Collins,D.C.)

4 ! COLLINS CHIROPRACTIC Are You Pregnant? (Check) Yes No How are your symptoms changing? Getting better Not changing Getting worse By Using the key below, indicate on the body diagram where you are experiencing the following symptoms: N=Numbness B=Burning S=Sharp T=Tingling A=Dull Ache Average Pain Intensity: Last 24 hours: no pain worst pain Past week: no pain worst pain Does anything improve your pain? Yes No If Yes, please list: When/How did your symptoms begin? Are your symptoms a result of: Motor Vehicle Accident Work related Accident Other How often do you experience your symptoms? Constantly Frequently Occasionally Intermittently (76-100% of the day) (51-75% of the day) (26-50% of the day) (0-25% of the day) What describes the nature of your symptoms? Sharp Ache Numb Shooting Burning Tingling Throbbing Other Doctor s Signature (Daniel L. Collins,D.C.)

5 PAYMENT POLICY Thank you for choosing Dr. Daniel Collins as your Chiropractic provider. We are committed to providing you with quality and affordable health care. Please read and sign in the space provided below. A copy will be provided to you upon request. 1. INSURANCE. We participate in Blue Cross Blue Shield of Michigan, Blue Care Network, Government VA insurance and Medicare. If you are not insured by a plan we participate with, payment in full is expected at each visit. If you are insured by a plan we do participate with, but do not have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility, please contact your insurance company with any questions you may have regarding your coverage. If your insurance company requires a referral it is your responsibility to provide us with a referral dated the day of your first visit from your primary care physician prior to your first visit. We are only able to provide a summary of your chiropractic benefits. 2. CO-PAYMENT AND DEDUCTIBLES. All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit. 3. PROOF OF INSURANCE. All patients must complete our patient information form before seeing Dr. Collins. We must obtain a copy of your most current insurance card to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim. 4. CLAIM SUBMISSION. We will submit your claims and assist you in any way we reasonably can to help get your claim paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance pays your claim. Your insurance benefits are a contract between you and your insurance company; we are not party to that contract. 5. COVERAGE CHANGES. If your insurance coverage changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 90 days, the balance will automatically be billed to you. 6. MISSED APPOINTMENT. Our policy is to charge $25.00 after one missed appointment not cancelled 24 hours in advance. The charges will be your responsibility and billed directly to you. Please help us to serve you better by keeping your regular scheduled appointment. 7. MONTHLY STATEMENT. If you have a balance on your account you will be billed promptly. Your bill will provide an itemized statement of the amount billed per visit. Unless we approve other payment arrangements in writing, the balance on your statement is due upon receipt of your bill. 8. BILLING AND COLLECTION FEES. Failure to pay an outstanding balance can result in further collection activity, reporting to credit bureaus, late charges and termination of patient relationship with Collins Chiropractic can be avoided by the timely payment of your account. There is a $33.00 charge for returned checks. Our practice is committed to providing the best treatment to our patients. I have read and understood the payment policy and agree to abide by its guidelines. Signature of patient or responsible party Date

6 Informed Consent for Chiropractic Care When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working toward the same objective. It is important that each patient understand both the objective and the method(s) that will be used to attain this objective. This will prevent any confusion or disappointment. You have the right, as a patient, to be informed about the condition of your health and the recommended care and treatment to be provided so that you may make the decision whether or not to undergo chiropractic care after being advised of the known benefits, risks and alternatives. Chiropractic is a science and art which concerns itself with the relationship between structure (primarily the spine) and function (primarily the nervous system) as that relationship may effect the restoration and preservation of health. Health is a state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity. One disturbance to the nervous system is called a vertebral subluxation. This occurs when one or more of the 24 vertebra in the spinal column become misaligned and/or do not move properly. This causes alteration of nerve function and interference to the nervous system. This may result in pain and dysfunction or may be entirely asymptomatic. Subluxations are corrected and/or reduced by an adjustment. An adjustment is the specific application of forces to correct and/or reduce vertebral subluxation. Our chiropractic method of correction is by specific adjustment of the spine. Adjustments are usually done by hand but may be performed by handheld instruments. In addition, ancillary procedures such as physiotherapy and/or rehabilitative procedures may be included. If during the course of care we encounter non-chiropractic or unusual findings, we will advise you of those findings and recommend that you seek the services of another health care provider. All questions regarding the doctor's objective pertaining to my care in this office have been answered to my complete satisfaction. The benefits, risks, and alternatives of chiropractic care have been explained to me to my satisfaction. I have read and fully understand the above statements and therefore accept chiropractic care on this basis. Print Name Signature Date Consent to evaluate and adjust a minor child: I, being the parent or legal guardian of have read and fully understand the above Informed Consent and hereby grant permission for my child to receive chiropractic care. Pregnancy Release This is to certify that to the best of my knowledge I am not pregnant and that the above doctor and his/her associates have my permission to perform an x-ray evaluation. I have been advised that x-ray can be hazardous to an unborn child. Date of last menstrual cycle: Signature Date

7 Health Insurance Portability and Accountability Act (HIPPA) I,, have received a copy of this offices notice of privacy practices. I understand that I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, plan and direct my treatment and follow up among the healthcare providers who may be directly and indirectly involved in providing my treatment. Obtain payment from third-party payers. Conduct normal healthcare operations such as quality assessments and accreditation. Patient Signature Date For Office Use Only We attempted to obtain a written acknowledgment of receipt of our notice of privacy practices, but acknowledgment could not be obtained because: Individual refused to sign Communications barriers prohibited obtaining the acknowledgment An emergency situation prevented us from obtaining acknowledgment Other (Please Specify) Staff signature Date

8 NOTES Daniel L. Collins, D.C.