Chiropractic Case History/Patient Information

Transcription

1 1 Dr. Gregory T. Kaumeyer, D.C., C.C.S.P., C.M.E. Chiropractic Case History/Patient Information 100 Ridgeway St., Suite 8 Hot Springs, Arkansas P F Date: Patient # Doctor: Name: Social Security # Home Phone: Address: City: State: Zip: address: Fax # Cell Phone: Age: Birth Date: Race: Marital: M S W D Occupation: Employer: Employer's Address: Office Phone: Spouse: Occupation: Employer: How many children? Names and Ages of Children: Name of Nearest Relative: Address: Phone: How were you referred to our office? Family Medical Doctor: When doctors work together it benefits you. May we have your permission to update your medical doctor regarding your care at this office? Please check any and all insurance coverage that may be applicable in this case: Major Medical Worker's Compensation Medicaid Medicare Auto Accident Medical Savings Account & Flex Plans Other Name of Primary Insurance Company: Name of Secondary Insurance Company (if any): AUTHORIZATION AND RELEASE: I authorize payment of insurance benefits directly to the chiropractor or chiropractic office. I authorize the doctor to release all information necessary to communicate with personal physicians and other healthcare providers and payors and to secure the payment of benefits. I understand that I am responsible for all costs of chiropractic care, regardless of insurance coverage. I also understand that if I suspend or terminate my schedule of care as determined by my treating doctor, any fees for professional services will be immediately due and payable. The patient understands and agrees to allow this chiropractic office to use their Patient Health Information for the purpose of treatment, payment, healthcare operations, and coordination of care. We want you to know how your Patient Health Information is going to be used in this office and your rights concerning those records. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent. Patient's Signature: Date:

2 2 HISTORY OF PRESENT AND PAST ILLNESS: Chief Complaint: Purpose of this appointment: Date symptoms appeared or accident happened: Is this due to: Auto Work Other Have you ever had the same or a similar condition? Yes No If yes, when and describe: Days lost from work: Date of last physical examination: Do you have a history of stroke or hypertension? Have you had any major illnesses, injuries, falls, auto accidents or surgeries? Women, please include information about childbirth (include dates): Have you been treated for any health condition by a physician in the last year? Yes No If yes, describe: What medications or drugs are you taking? Do you have any allergies to any medications? Yes No If yes, describe: Do you have any allergies of any kind? Yes No If yes, describe: Do you have any Congenital Condition? Yes No If YES, Describe Women: Are you pregnant? Have you had or do you now have any of the following symptoms/conditions? Please indicate with the letter N if you have these conditions now or P if you have had these conditions previously. N = Now P = Previously Headaches Frequency Loss of Balance Neck Pain Fainting Stiff Neck Loss of Smell Sleeping Problems Loss of Taste Back Pain Unusual Bowel Patterns Nervousness Feet Cold Tension Hands Cold Irritability Arthritis Chest Pains/Tightness Muscle Spasms Dizziness Frequent Colds Shoulder/Neck/Arm Pain Fever Numbness in Fingers Sinus Problems Numbness in Toes Diabetes High Blood Pressure Indigestion Problems Difficulty Urinating Joint Pain/Swelling Weakness in Extremities Menstrual Difficulties PATIENT NAME DATE

3 3 Breathing Problems Weight Loss/Gain Fatigue Lights Bother Eyes Loss of Memory Ears Ring Buzzing in Ears Broken Bones/Fractures Circulation Problems Rheumatoid Arthritis Seizures/Epilepsy Excessive Bleeding Low Blood Pressure Osteoarthritis Osteoporosis Pacemaker Heart Disease Stroke Cancer Ruptures Coughing Blood Eating Disorder Alchoholism Drug Addiction HIV Positive Gall Bladder Problems Depression Ulcers SOCIAL HISTORY Please indicate beside each activity whether you engage in it: OFTEN= O SOMETIMES= S NEVER= N Vigorous Exercise Moderate Exercise Alcohol Use Drug Use Tobacco Use Caffeine Family Pressures Financial Pressures Other Mental Stresses Other (specify) High Stress Activity Patient's Signature: Date:

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5 5 Kaumeyer Chiropractic Center Medical Information Release Form (HIPPA Release Form) Name: Date of Birth: Release of Information () I authorize the release of information including diagnosis and records of the examination rendered to me and claims information. This information may be released to: () Spouse () Child(ren) () Other () Information is not to be released to anyone. This Release of Information will remain in effect until terminated by me in writing. Messages Please call () My home () My work () My cell number: If unable to reach me: () You may leave a detailed message () Please leave a message asking me to return your call () The best time to call me is (day) between (time) Signed: Date:

6 6 Kaumeyer Chiropractic Center, LLC Dr. Gregory T. Kaumeyer, D.C., C.C.S.P., C.M.E. 100 Ridgeway Street, Suite 8 * Hot Springs, Arkansas Payment Policy Thank you for choosing us as your primary care provider. We are committed to providing you with quality and affordable health care. Because some of our patients have had questions regarding patient and insurance responsibility for services rendered, we have been advised to develop this payment policy. Please read it, ask us any questions you may have, and sign in the space provided. A copy will be provided to you upon request. 1. Insurance. We participate in most insurance plans, including Medicare. If you are not insured by a plan we do business with, payment in full is expected at each visit. If you are insured by a plan we do business with, but don t 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. Our office does NOT accept 3 rd party liens for auto accidents. We accept ONLY Med-Pay from personal auto insurance. If other arrangements have been made with Kaumeyer Chiropractic Center, then payment in full is expected from patient, no later than 90 days from release of treatment. This is the patient s responsibility not Auto Insurance Company. 2. Copayments and Deductibles. All co-payments and deductibles must be paid at 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 patient s can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit. 3. Non-covered services. Please be aware that some, and perhaps all, of the services you receive may be non-covered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of the visit. 4. Proof of Insurance. All Patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver s license and current valid insurance 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 the claim.

7 7 5. Claims Submission. We will submit your claims and assist you in any way we reasonably can to help get your claims 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 company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract. 6. Coverage changes. If your insurance 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 45 days, the balance will automatically be billed to you. 7. Nonpayment. If your account is over 90 days past due, you will receive a letter stating that you have 20 days to pay your account in full. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you and your immediate family members may be discharged from this practice. If this is to occur, you will be notified by regular and certified mail that you have 30 days to find alternative medical care. During that 30 day period, our physician will only be able to treat you on an emergency basis. 8. Missed appointments. Our policy is to charge for missed appointments not canceled within a reasonable amount of time. These charges will be your responsibility and billed directly to you. Please help us to serve you better by keeping your regularly scheduled appointment. Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area. Thank you for understanding our payment policy. Please let us know if you have any questions or concerns. I have read and understand the payment policy and agree to abide by its guidelines: Signature of patient or responsible party Date