PURE WELLNESS CHIROPRACTIC
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- Johnathan McBride
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1 PURE WELLNESS CHIROPRACTIC PATIENT INFORMATION Date: / / Male: Female: Name: Preferred t be called: Mr. Mrs. Ms. Miss Dr. Birthdate: / / Age: SS#: - - DL#: Hme Address: City: Zip Cde: Single: Married: Divrced: Separated: Hm#: Cell#: Wrk#: Where and when are the best times t reach yu? Emplyer: # f Years Emplyed: Occupatin: Emplyer Address: Whm may we thank fr referring yu? Other family members seen by us: GUARANTOR INFORMATION Name: Relatin t patient: Insurance Prvider: Hm#: Cell#: Wrk#: Emplyer: Emplyer Address: # f Years Emplyed: Birthdate: / / SS#: - - EMERGENCY NOTIFICATION INFORMATION In the event f an emergency, is there smene wh lives near yu and/r a physician we can cntact? Name: Relatin t patient: Hm#: Cell#: Wrk#: Physician: Office#:
2 HEALTH CARE AUTHORIZATION FORM Patient Name Patient SS# Date f Birth THE PATIENT IDENTIFIED ABOVE AUTHORIZES PURE WELLNESS CHIROPRACTIC TO USE AND OR DISCLOSE PROTECTED HEALTH INFORMATION IN ACCORDANCE WITH THE FOLLOWING: SPECIFIC AUTHORIZATIONS ****** I give permissin t Pure Wellness Chirpractic t use my address, phne numbers, and clinical recrds t cntact me with birthday cards, hliday related cards, thank yu ntes, recall cards, infrmatinal , and infrmatin abut alternative treatments r ther health related infrmatin. ****** By Signing this frm yu are giving the chirpractic ffices f Pure Wellness Chirpractic permissin t use and disclse yur prtected health infrmatin in accrdance with the directives listed abve. RIGHT TO REVOKE AUTHORIZATION Yu have the right t revke this AUTHORIZATION, in writing, at any time. Hwever, yur written request t revke this AUTHORIZATION is nt effective t the extent that we have prvided services r taken actin in reliance n yur authrizatin. Yu may revke this AUTHORIZATION by mailing r hand delivering a written ntice t Dr. Mary Surkein, the privacy fficial f Pure Wellness Chirpractic. The written ntice must cntain the fllwing infrmatin: A. Yur name, scial security number and date f birth B. A clear statement f yur intent t revke this AUTHORIZATION C. The date f yur request, and yur signature The revcatin is nt effective until it is received by the privacy fficial. Pure Wellness Chirpractic requests this AUTHORIZATION. If yu refuse this AUTHORIZATION, Pure Wellness Chirpractic will nt refuse t prvide treatment. Yu have the right t inspect r cpy the PHI t be used/disclsed. **A COPY OF THIS AUTHORIZATION WILL BE PROVIDED FOR YOU** Patient Name Signature Date
3 INFORMED CONSENT TO CHIROPRACTIC CARE Dctrs f chirpractic wh use manual therapy techniques are required t advise patients that there are r may be sme risks assciated with such treatment. In particular yu shuld nte: A. While rare, sme patients may experience shrt term aggravatin f symptms, rib fractures r muscle and ligament strains r sprains as a result f manual therapy techniques. B. There are reprted cases f strke assciated with many cmmn neck mvements including adjustment f the upper cervical spine. Present medical and scientific evidence des nt establish a definite cause and effect relatinship between upper cervical spine adjustment and the ccurrence f strke. Furthermre, the apparent assciatin is nted very infrequently. Hwever, yu are being warned f this pssible assciatin because strke smetimes causes serius neurlgical impairment, and may n rare ccasin result in injuries including paralysis. The pssibility f such injuries resulting frm upper cervical spinal adjustment is extremely remte. C. There are rare reprted cases f disc injuries fllwing cervical and lumbar spinal adjustment althugh n scientific study has ever demnstrated such injuries are caused, r may be caused by spinal adjustments r chirpractic treatment. Chirpractic treatment, including spinal adjustment has been the subject f gvernment reprts and multi-disciplinary studies cnducted ver many years and has been demnstrated t be effective treatment fr many neck and back cnditins invlving pain, numbness, muscle spasm, lss f mbility, headaches and ther similar symptms. Chirpractic care cntributes t yur verall wellbeing. The risk f injuries r cmplicatins frm chirpractic treatment is substantially lwer than that assciated with many medical r ther treatments, medicatins, and prcedures given fr the same symptms. I acknwledge I have discussed, r have had the pprtunity t discuss, with my chirpractr the nature and purpse f chirpractic treatment in general and my treatment in particular (including spinal adjustment) as well as the cntents f this Cnsent. I cnsent t the chirpractic treatments ffered r recmmended t me by my chirpractr, including spinal adjustment. I intend this cnsent t apply t all my present and future chirpractic care. Dated this day f, 20. Patient Signature (r Legal Guardian)
4 PURE WELLNESS CHIROPRACTIC Assignment f Benefits/ Cntractual Lien/ Assignment f Cause f Actin The undersigned patient and/r respnsible party, in additin t cntinuing persnal respnsibility, and in cnsideratin f treatment rendered r t be rendered assigns t Mary Surkein, D.C., the fllwing rights, pwer and authrity: RELEASE OF INFORMATION: Yu are authrized t release infrmatin cncerning my cnditin and treatment t my insurance cmpany, attrney r insurance adjuster fr purpsed f prcessing my claim fr benefits and payment f serviced rendered t me. IRREVOCABLE ASSIGNMENT OF RIGHTS: Yu are assigned the exclusive, irrevcable right t any cause f actin that exists in my favr against any insurance cmpany fr the terms f the plicy, including the exclusive, irrevcable right t receive payment fr such services, make demand in my name fr payment, and prsecute and receive penalties, interest, r curt lss, r ther legally cmpensable amunts wned by an insurance cmpany in accrdance with Article f the Texas Insurance Cde t cperate, prvide infrmatin as needed, and appear as needed, wherever t assist in the prsecutin f such claims fr the benefits upn request. DEMAND FOR PAYMENT: T any insurance cmpany prviding benefits f any kind t me/us fr treatment rendered by the physician/ facility named abve, yu are hereby tendered demand t pay in full the bill fr services rendered the physician/facility named abve within 30 days fllwing yur receipt f such bill fr services t the extent such bills are payable under the terms f the plicy. This demand specifically cnfrms t Article f the Texas Insurance Cde, prviding fr attrney fees, 18% penalty, curt cst, and interest frm judgment, upn vilatin. I further instruct the prvider t make all checks payable t Pure Wellness Chirpractic, and t send all checks t 6853 Cit Rad, Plan TX THIRD PARTY LIABILITY: I waive my rights t claim any statute f limitatins regarding claims fr services rendered r t be rendered by the physician/facility named abve, in additin t reasnable cst f cllectin, including attrney fees and curt cst incurred. LIMITED POWER OF ATTORNEY: I hereby grant t the physician/facility named abve the pwer t endrse my name upn any checks, drafts, r ther negtiable instrument representing payment frm any insurance cmpany representing payment fr treatment and healthcare rendered by the physician/facility named abve. I agree that any insurance payment representing and amunt in excess f the charges fr treatment rendered will be credited t my/ur accunt r frwarded t my/ur address upn request in writing t the physician/facility named abve. TERMINATION OF CARE: I hereby acknwledge and understand that if I d nt keep my appintments as recmmended t me by my caring dctr at the clinic, he/she has full and cmplete right t terminate respnsibility fr my care and relinquish any disability granted me within a reasnable perid f time. If during the curse f my care, my insurance cmpany requires me t take an examinatin frm any ther dctr; I will ntify this physician/facility immediately. I understand that failure t d s may jepardize my case. Signature f patient and/r respnsible parties: Date
5 PUREWELLNESS CHIROPRACTIC Health Questinnaire Where are yu hurting tday? What is the cause f yur pain? Rate yur pain: ( 1= nt severe 10= very severe ) List any dctrs seen fr this cnditin: Did yu receive any treatment and if s what treatment: Have yu had similar symptms befre? Y r N If yes, explain: Have yu had chirpractic treatment previusly? Y r N If yes, where: Are yu currently taking any medicatins? Y r N If yes, then list: Have yu been hspitalized? Y r N If yes, explain: List any surgeries: What are yur health gals? Mnthly: Yearly: D yu have a desire t lse weight? D yu have truble with weight lss? If yes, what have yu tried that has failed? Habits Exercise Family Histry Smking Packs/Day Alchl Drinks/Day Cffee Cups/Day Nne Mderate Daily Diabetes Heart Kidney Cancer Mther Father Brther # Sister # Please mark if yu currently r previusly have had the fllwing symptms: General Symptms Cardivascular Muscle and Jints Skin and Allergies Cnvulsins Bld Pressure Lw Back Prblems Bils Dizziness Pain Over Heart Pain Btwn Shulder Blades Bruising Easily Fainting Pr Circulatin Neck Prblems Dryness Headache Heart Truble Arm Prblems Eczema Nervusness Rapid Heart Leg Prblems Hives Numbness Slw Heart Swllen Jints Itching Wheezing Strkes Stiff Jints Sensitive Skin Swelling Ankles Sre Muscles Allergies: Varicse Veins Weak Muscles Walking Prblems Ruptures Brken Bnes
6 Gastrintestinal Urinary Fr Wmen Only Belching/Gas Bld In Urine Cln Truble Frequent Urinatin Cnstipatin Kidney Infectin Diarrhea Painful Urinatin Excessive Hunger Prstate Truble Excessive Thirst Bladder Truble Hemrrhids Liver Truble Nausea Pain Over Stmach Pr Appetite Pr Digestin Vmiting Bldy Stl Weight Truble Cramps/Backaches Excessive Flw Ht Flashes Irregular Cycle Miscarriage Painful Perids Vaginal Discharge Breast Pain Pregnant At This Time Please mark areas & types f pain n the fllwing drawing using the cdes listed belw N- Numbness T-Tingling S- Sreness P- Pain A- Ache St- Stiffness I understand and agree that health and accident insurance plicies are an arrangement between an insurance carrier and myself. Furthermre, I understand the dctr s ffice will prepare any necessary reprts and frms t assist me in making cllectin frm the insurance cmpany and that any accunt authrized t be paid directly t the dctr s ffice will be credited t any accunt r receipt. Hwever, I clearly understand and agree that all services rendered are charged directly t me and that I am persnally respnsible fr payment. I als understand that if I suspend r terminate my care and treatment, any fees fr prfessinal services rendered t me will be immediately due and payable. I hereby authrize the dctr t examine and treat any cnditin as he deems apprpriate thrugh the use f Chirpractic Health Care and I give authrity t these prcedures t be perfrmed. It is understd and agreed the amunt paid t the dctr fr x-rays is fr examinatin nly and the x-ray negatives will remain the prperty f this ffice, being n file where they may be seen at any time while a patient at this ffice. The patient als agrees that he/she is respnsible fr all bills incurred at this ffice. The dctr will nt be held respnsible fr any pre-existing medically diagnsed cnditins nr fr any medical diagnsis. Patient s / Guardian s Signature Date
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