SHOOK FAMILY CHIROPRACTIC, INC.

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Linda Corey Nichols
5 years ago
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1 PATIENT APPLICATION FOR TREATMENT PLEASE CIRCLE THE TYPE OF CARE DESIRED: TEMPORARY LASTING RELIEF DATE: Name: SSN: Date of Birth: Address: City: State: Zip: Cell: Home: Work: Name of Spouse: Ages of Children: Circle if you are: MARRIED SINGLE WIDOWED DIVORCED SEPARATED Employment: Spouse Employment: Referred to our office by: Is there anyone else that you may know that may benefit from chiropractic care? Circle who is responsible for you care? SELF SPOUSE EMPLOYER Payment will be made by? CASH CREDIT CARD WORKER S COMP AUTO INSURANCE HEALTH INSURANCE If you are in pain, mark the exact location of our pain on the diagram below. Also describe the type and frequency of your pain, as well as any activity which brings on or aggravates the pain. For example, dull, sharp, constant, off & on, when standing, etc. MAJOR COMPLAINT (MAJOR PROBLEM ONLY) How did this condition develop? What caused it? How did it start? When was the first time you were aware of this problem? Have you ever had this problem or a similar problem before? Have you ever received any treatment for this condition? If yes, where and when, and what were your results? Have you ever received chiropractic care? If yes, for what condition? Is there anything you do that makes your condition worse? How has this condition affected your life? Home life? Occupational life? Rest and sleep? Recreational life? Have you ever been in a automobile accident? yes no If so, When? Any accidents, falls, etc. that might have caused your problem? What surgery has been done? Drugs you now take: Patient Signature: Date:

Shook Family Chiropractic, Inc. 1511 NW Blvd.

2 Shook Family Chiropractic, Inc NW Blvd. Newton, North Carolina (828) Assignment, Lien and Authorization To Whom It May Concern: I hereby authorize and direct you my insurance company, and/or attorney to pay directly to Shook Family Chiropractic, Inc. such sums as may be due and owing this office for services rendered to me, both by reasons of accident or illness and by reason of any other bills that are due this office. I further authorize you to withhold such sums from any disability benefits, medical payments benefits, no-fault benefits or any other insurance benefits obligated to reimburse me or from any settlement, judgment or verdict on my behalf as may be necessary to adequately protect said office. I hereby further give lien to said office against any and all insurance benefits named herein and any and all proceeds of any settlement, judgment or verdict which may be paid to me as a result of the injuries or illness for which I have been treated by said office. This is to act as an assignment of my rights and benefits to the extent of Shook Family Chiropractic, Inc. s services provided. In the event my insurance company obligated to make payments to me upon the charges made by this office for their services, refuses to make such payments, and upon demand by me or this office, I hereby assign and transfer to this office any and all causes of action that I might have or that might exist in my favor against such company. I authorize this office to prosecute said cause of action either in my name or in this office s name and further, I authorize this office to compromise, settle or otherwise resolve said claim or cause of action as they see fit. In the event that our lien is paid on a pro-rata basis, please provide this office with the following information pursuant to N.C.G.S : (1) the total settlement amount; (2) the total distribution to lienholders, amount of each lien claimed, and the percentage of each lien paid; and (3) the total attorney s fees. This office is happy to execute a confidentiality agreement regarding the contents of such an accounting upon your request. In the event your office no longer represents this client cease representation of this client in the future, please advise me of that in writing. Otherwise, please call with any problems or questions you may have. I understand that I remain personally responsible for the total balance due Shook Family Chiropractic, Inc. for their services. I further understand and agree that this assignment, lien and authorization does not constitute any consideration for this office to await payments and they may request payments from me immediately upon rendering service, at their option. I authorize this office to release any information pertinent to any case to any insurance company, adjuster or attorney to facilitate collection under the assignment, lien and authorization. I agree that Shook Family Chiropractic, Inc. be given power of attorney to endorse/sign my name on any and all checks for payment of my bill. Signed date Witness date

3 1511 NORTHWEST BLVD. NEWTON, NORTH CAROLINA (828) ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges: 1. The right to review the notice prior to signing this consent, 2. The right to object to the use of my health information for directory purposes, and 3. The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations. Patient Signature Date

4 1511 NW BLVD, NEWTON, N.C PHONE: (828) Patient Name: Date: To the best of my knowledge, there is no pregnancy confirmed or suspected at this time. Patient Signature

5 Witness

W E L C O M E. Name Date Address Apt # City State Zip Code Phone #: Home Cell Work Referred By

W E L C O M E. Name Date Address Apt # City State Zip Code Phone #: Home Cell Work Referred By W E L C O M E PATIENT INFORMATION Name Date Address Apt # City State Zip Code Phone #: Home Cell Work Referred By Date of Birth Social Security # - - Gender: Male Female Marital Status (please circle):