Welcome to Grove Spine & Sports Care!

Transcription

1 Welcome to Grove Spine & Sports Care! We want to make sure your visits to Grove Spine & Sports Care are pleasant, productive, and stressfree. We hope to make your experience one that is positive and that will assist you in returning to your active lifestyle. The following is important information regarding your upcoming visits to our clinic. Initial Visit Your first visit will include a medical history, thorough evaluation and treatment, if time permits. The more complex the case, the more important the history and evaluation are in determining the proper course of treatment. Your doctor will provide you with helpful information regarding your condition and will outline a treatment plan so you will know what to expect during each follow up visit. A typical initial visit lasts one hour. Follow up Visits All subsequent visits are approximately minutes in length. Please arrive before your scheduled appointment time so you are ready to go(changed, etc.). The doctors usually run on time so if you expect to be late for your appointment, please call our office as we may have to reschedule your appointment. Please wear (or bring with you) comfortable work out style clothing for each treatment. We do have shorts and tee shirts for your use if you forget to bring your own. Homework! You may be given exercises or stretches to perform on your own between visits. Your participation in improving your health is just as important as ours, so please do all exercises/stretches as instructed. Financial Information When you check out at the end of each visit, payment for service is expected. Our clinic participates with Blue Cross Blue Shield PPO insurance plans only (Federal plans are handled differently, please ask for more information).your insurance plan may have a deductible and/or co-payments or co-insurance for which you are responsible. We will file BCBS claims on your behalf. We will do our best to ascertain your level of coverage at our office but ultimately it is your responsibility to understand your coverage. To obtain information about your specific plan, we encourage you to contact your insurance company's customer service department. Grove Spine & Sports Care 8130 Boone Boulevard, Suite 110 Vienna, VA (fax) FrontOffice@grovespinesports.com

2 Grove Spine & Sports Care Center for Sports Injuries, Chiropractic & Rehab Patient Information Sheet Thank you for entrusting your health to Grove Spine & Sports Care. We will do our utmost to provide you with the best possible care and service. The Front Office handles all patient scheduling and any financial/insurance questions you may have. Office Phone: (703) Fax: (703) Hours: Monday 7:30AM to 6:30PM Tuesday 7:30AM to 4:00PM Wednesday 7:30AM to 6:30PM Thursday 8:00AM to 4:30PM Friday 7:30AM to 12:00PM **GPS directions may not always be accurate. Feel free to ask Front Desk staff for directions once you are in the Tyson's area.

3 Grove Spine & Sports Care Patient Intake Form Last Name: First Name: Date: Address: City: State: Zip: Sex: M F Age: _ Birth date: Height: Weight: Marital Status: Single Married Divorced Other Home Phone: Work Phone: Cell Phone: Occupation: Retired Note: Our office will do appointment reminders two days prior to your appointment date. We require 24 hours for a cancellation notice. Please select reminder preference: Home Cell Work Who may we thank for referring you/how did you hear about us? Physician Patient Website Event Other Name of referral (i.e person/website/event) : Name of emergency contact: Best phone number to reach emergency contact: Relationship: Reason for Visit What is the purpose of your visit? Injury Complaint Wellness Other * PLEASE INDICATE AREAS OF PAIN ON THE DIAGRAM * (Mark an 'X' on area of pain) Where is the injury located on your body? Date of injury: Please describe how the injury, pain, discomfort started: Please describe your pain/discomfort:

4 Have you ever had this same condition? Y N If yes, when?: How often do you experience your symptoms? Constantly (100% of day) Frequently (25-75% of day) Intermittently (0-25% of day)...during the past 4 weeks: Does your injury interfere with any of your daily activities? Y N Does your injury interfere with your sleep? Y Does your injury interfere with your appetite? Y N N Is the condition getting progressively worse? Y N Unknown List anything that aggravates your condition: List anything that relieves or improves your condition: Rate the pain, on a scale from 0 (least) to 10 (most severe): What are your goals for treatment?: Please check all that apply: Type of Pain: Painful activities: Does it interfere with: Sharp Burning Sitting Standing Work Dull Tingling Walking Bending Sleep Throbbing Cramps Lying down Recreation Shooting Numbness Daily routine Stiffness Aching Swelling Other: Have you seen other doctors for these symptoms? If yes, please indicate name, type of provider, & when seen: Any medical diagnosis of your condition?: What tests have you had for your condition? Xrays date: CT Scan date: MRI date: Other date:

5 Medical History Primary care physician: Phone: Date of last physical: Last Blood Pressure Reading if known: / mmhg May we update them on your condition? Y N Have you consulted a chiropractor in the past? Y N (Name): Date consulted: For what conditions? Broken Bones? Y N If yes, briefly explain: Been Hospitalized? Y N If yes, briefly explain: Been in an Auto Accident? Y Had Major Sprains/Strains? Y N If yes, briefly explain: N If yes, briefly explain: Had Surgery? Y N If yes, briefly explain: Have you ever been hit in the head? If yes, briefly explain: Been Struck Unconscious? Y N If yes, did you get professional care/treatment? Briefly explain: Had a Stroke? Y N If yes, briefly explain: Please indicate if you have had the condition in the past or if you presently have the condition: Past Present Past Present Past Present Abdominal Pain Depression Thigh/upperleg pain Abnormal Weight gain/loss Allergies Ankle/foot pain Arthritis Asthma Bladder infection Bleeding tendency Birth control pills Broken bones Back problems Cancer Chest pains Chronic Sinusitis Dermatitis/Eczema Diabetes/Gestational diabetes Dizziness Elbow/upper arm pain Epilepsy Frequent Urination General fatigue Gout Hand pain Heart disease Hepatitis High blood pressure HIV/AIDS Jaw pain Joint swelling/ stiffness Kidney disease Knee/lower leg pain Liver/Gall Bladder Disorder Low back pain Mid back pain Migraines w/ aura Neck pain Nervous conditions Pre-eclampsia

6 Medical History Conditions cont'd... Past Present Prostate Problems Shoulder pain Past Present Stroke Systematic Lupus Past Present Ulcers Upper back pain Wrist pain Family History (list all major diseases such as cancer, diabetes, heart problems, bone/joint diseases if bloodrelated family members): Additional Information List current medications: (name, amount, frequency, length of use, reason for use). Separate details with a comma as shown. List current vitamins: (name, amount, frequency, length of use, reason for use). Separate details with a comma as shown. Allergies to any medications? (For women) Date of last Menses: Are you pregnant? Y N Do you smoke?: Y N Amount per week?: Alcohol consumption? Y N Number of drinks: per Day Week Month Are you dieting? Y N If yes, please explain: Amount of rest and sleep per night: Regular exercise programs (type and frequency): Any particular sport you play? Hours per week: Other recreational hobbies/activities: Do you wear a: Pacemaker Defibrillator (implanted) Are you presently using any type of back or arch supports, orthotics, heel lifts, or braces, of any kind? Yes No If yes, please describe: If runner/triathlete, what is the make & model of current running shoes:

7 Informed Consent for Chiropractic Treatment PATIENT NAME: To the patient: Please read this entire document prior to signing it. It is important that you understand the information contained in this document. Please ask questions before you sign if there is anything that is unclear. The nature of the chiropractic adjustment: One of the treatments we use as Doctors of Chiropractic is spinal adjustive therapy. The doctors at Grove Spine & Sports Care may use that procedure to treat you. We may use our hands or a mechanical instrument upon your body in such a way as to move your joints within their normal range of motion. This may cause an audible pop or click, much as you have experienced when you crack your knuckles. You may feel a sense of movement. Analysis/Examination/Treatment As a part of the analysis, examination and treatment, you are consenting to the following possible procedures : spinal adjustive therapy palpation vital signs range of motion testing orthopaedic testing basic neurological testing muscle strength testing postural analysis dry needling ultrasound Kinesio taping Functional Movement screening Active Release Techniques Graston The material risks inherent in chiropractic adjustment: As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation and therapies such as Graston, dry needling and Active Release Technique. These complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, cervical myelopathy, costovertebral strains, separations, burns and pneumothorax. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. Some patients will feel some stiffness and soreness following the first few days of treatment. The doctors will make every reasonable effort during the examination to screen for contraindications to care; however, if you have a condition that would otherwise not come to our attention, it is your responsibility to inform us. The probability of those risks occurring: Fractures are rare occurrences and generally result from underlying weakness of the bone which we check for during the taking of your history and during examination. Stroke has been the subject of tremendous disagreement. The incidences of stroke are exceedingly rare and are estimated to occur between one in one million and one in five million cervical adjustments. The other complications are also generally described as rare. The availability and nature of other treatment options: Other treatment options for your condition may include: Self administered, over the counter analgesics and rest Medical care and prescription drugs such as anti inflammatory, muscle relaxants and pain killers Hospitalization Surgery The risks and dangers attendant to remaining untreated: Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed. Do not sign until you have read and understand the above.

8 Please check the appropriate block and sign below. I have read [ ] or have had read to me [ ] the above explanation of the chiropractic adjustment and related treatment. I have discussed it with Dr. and have had my questions answered to my satisfaction. By signing below I state that I have weighed the risks involved in undergoing treatment and have decided that it is in my best interest to undergo the treatment recommended. Having been informed of the risks, I hereby give my consent to that treatment. Dated: Dated: Patient's Name Doctor's Name Signature Signature Signature of Parent or Guardian (if a minor)

9 FINANCIAL POLICY Thank you for choosing our practice for your chiropractic care. We are committed to providing the best treatment for our patients, and we appreciate your trust in us. To help us serve you, please provide us with accurate and complete insurance information. Insurance policies are arrangements between the carrier and the patient. The patient is ultimately responsible for the payment for all services received from this office. Payment is due in full at the time of service (includes insurance deductibles and co-payments). We accept cash, checks or VISA/MASTERCARD, and we offer an extended payment plan with prior approval. We process insurance claims only for Blue Cross/Blue Shield related insurance. Thank you for reviewing our Financial Policy. Please let us know if you have any questions or concerns. Signature: Date Blue Cross / Blue Shield PPO & Medicare Patients Only: Please provide the following information: Patient name: Person responsible for account: Subscriber s Insurance I D #: Group # Insurance Co.: Ins. Co. Telephone: Ins. Co. Address: Is patient covered by additional insurance? Yes No ASSIGNMENT OF INSURANCE I, the undersigned, assign directly to Grove Spine & Sports Care. all relevant insurance benefits, if any. I understand that I am financially responsible for all charges not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. Signature Date

10 Patient Attendance Policy In order to assure that all patients receive the time and attention they deserve, we have the following guidelines: 1. If you are late for a scheduled appointment, there is a possibility that you may not be seen that day. We do not run over the original time allotted to your appointment. 2. If you need to cancel an appointment, it must be done at least 24 hours in advance. If your call is not during our normal business hours, please leave a message on our voice mail. There is a $30.00 fee for a cancellation without proper notice. This charge will not be covered by insurance and will be billed directly to you. 3. Your appointment time is reserved for you. If you do not give the required notice and you miss your scheduled appointment (no call/no show), we have the right to assess a $50.00 charge. This charge will not be covered by insurance and will be billed directly to you. I have read and understand this policy. Patient/Guardian Signature: Date:

11 NOTICE OF PRIVACY PRACTICES Grove Spine & Sports Care 8110 Boone Blvd., Ste. 110 Vienna, VA Effective Date: February 7, 2014 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY. This Notice of Privacy describes how we may use and disclose your Protected Health Information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your PHI. Protected Health Information is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health condition and related health care services. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION Treatment: We may use and disclose your personal information to provide you with treatment or services. For example, we may use your health information to prescribe a course of treatment or make a referral. We will record your current healthcare information in a record so, in the future, we can see your medical history to help in diagnosing and treatment, or to determine how well you are responding to treatment. We may provide your health information to other health providers, such as referring or specialist physicians, to assist in your treatment. Should you ever be hospitalized, we may provide the hospital or its staff with the health information it requires to provide you with effective treatment. Payment: We may use and disclose your health information so that we may bill and collect payment for the services that we provided to you. For example, we may contact your health insurer to verify your eligibility for benefits, and may need to disclose to it some details of your medical condition or expected course of treatment. We may use or disclose your information so that a bill may be sent to you, your health insurer, or a family member. The information on or accompanying the bill may include information that identifies you and your diagnosis, as well as services rendered, any procedures performed, and supplies used. Also, we may provide health information to another health care provider, such as an ambulance company that transported you to our office, to assist in their billing and collection efforts. Health Care Operations: We may use and disclose your health information to assist in the operation of our practice. For example, members of our staff may use information in your health record to assess the care and outcomes in your case and others like it as part of a continuous effort to improve the quality and effectiveness of the healthcare and services we provide. We may use and disclose your health information to conduct cost-management and business planning activities for our practice. We may also provide such information to other health care entities for their health care operations. For example, we may provide information to your health insurer for its quality review purposes. Other Permitted and Required Uses and Disclosure will be made only with your consent, authorization or opportunity to object unless required by law. You may revoke the authorization, at any time, in writing, except to the extent that your physician or the physician s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

12 Your Health Information Rights The following are statements of your rights with respect to your protected health information. Right to Obtain a Paper Copy of This Notice: You have the right to a paper copy of this Notice of Privacy Practices at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy. Right to Inspect and Copy: You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but does not include psychotherapy notes. You have a right to information that is stored electronically that is not in EHR software, including information stored in MS Word, Excel, PDF, plain text and other electronic formats. To inspect and copy medical information, you must submit a written request to our privacy officer. We will supply you with a form for such a request. If you request a copy of your medical information, we may charge a reasonable fee for the costs of labor, postage, and supplies associated with your request. We may not charge you a fee if you require your medical information for a claim for benefits under the Social Security Act or any other state or federal needs-based benefit program. If your medical information is maintained in an electronic health record, you also have the right to request that an electronic copy of your record be sent to you or to another individual or entity. We may charge you a reasonable cost based fee limited to the labor costs associated with transmitting the electronic health record. You have a right to have this information with-in 30 days of receipt of your request. Right to Amend: If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as we retain the information. To request an amendment, your request must be made in writing and submitted to our privacy officer. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that: was not created by us, unless the person or entity that created the information is no longer available to make the amendment; is not part of the medical information kept by or for Grove Spine & Sports Care is not part of the information which you would be permitted to inspect and copy; or is accurate and complete. If we deny your request for amendment, you may submit a statement of disagreement. We may reasonably limit the length of this statement. Your letter of disagreement will be included in your medical record, but we may also include a rebuttal statement. Right to an Accounting of Disclosures: You have the right to request an accounting of disclosures of your health information made by us. In your accounting, we are not required to list certain disclosures, including: disclosures made for treatment, payment, and health care operations purposes or disclosures made incidental to treatment, payment, and health care operations, however, if the disclosures were made through an electronic health record, you have the right to request an accounting for such disclosures that were made during the previous 3 years; disclosures made pursuant to your authorization; disclosures made to create a limited data set; disclosures made directly to you. To request an accounting of disclosures, you must submit your request in writing to our privacy officer. Your request must state a time period which may not be longer than six years and may not include dates before April 14, Your request should indicate in what form you would like the accounting of disclosures (for example, on paper or electronically by ). The first accounting of disclosures you request within any 12 month period will be free. For additional requests within the same period, we may charge you for the reasonable costs of providing the accounting of disclosures. We will notify you of the costs involved and you may choose to withdraw or modify your request at that time, before any costs are incurred. Under limited circumstances mandated by federal and state law, we may temporarily deny your request for an accounting of disclosures.

13 Right to Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the medical information we communicate about you to someone who is involved in your care or the payment for your care. You have a right to restrict certain disclosures of Protected Health Information to a health plan where you have paid out of pocket in full for the healthcare item or service. As noted above, we are not required to agree to your request. If we do agree, we will comply with your request unless the restricted information is needed to provide you with emergency treatment. To request restrictions, you must make your request in writing to our privacy officer. In your request, you must tell us what information you want to limit, whether you want to limit our use, disclosure, or both and to whom you want the limits to apply. Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by . To request confidential communications, you must make your request in writing to our privacy officer. We will accommodate all reasonable requests. Right to Receive Notice of a Breach: We are required to notify you by first class mail or by (if you have indicated a preference to receive information by ), of any breaches of Unsecured Protected Health Information as soon as possible, but in any event, no later than 60 days following the discovery of the breach. Unsecured Protected Health Information is information that is not secured through the use of a technology or methodology identified by the Secretary of the U.S. Department of Health and Human Services to render the Protected Health Information unusable, unreadable, and undecipherable to unauthorized users. Chiropractic Residents and Chiropractic Students. Medical residents or medical students may observe or participate in your treatment or use your health information to assist in their training. You have the right to refuse to be examined, observed, or treated by medical residents or medical students. Appointment Reminders. We may use and disclose Information in your medical record to contact you as a reminder that you have an appointment at Grove Spine & Sports Care. We usually will call you at home the day before your appointment and leave a message for you on your answering machine or with an individual who responds to our telephone call. However, you may request that we provide such reminders only in a certain way or only at a certain place. We will endeavor to accommodate all reasonable requests. Treatment Options. We may use and disclose your health information in order to inform you of alternative treatments. Release to Family/Friends. Our health professionals, using their professional judgment, may disclose to a family member, other relative, close personal friend or any other person you identify, your health information to the extent it is relevant to that person s involvement in your care or payment related to your care. We will provide you with an opportunity to object to such a disclosure whenever we practicably can do so. We may disclose the health information of minor children to their parents or guardians unless such disclosure is otherwise prohibited by law. Health-Related Benefits and Services. We may use and disclose health information to tell you about health-related benefits or services that may be of interest to you. In face -to-face communications, such as appointments with your physician, we may tell you about other products and services that may be of interest you. Complaints If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the U.S. Department of Health and Human Services. We will not retaliate against you for filing a complaint. To file a complaint with us, contact our privacy officer at the address listed above. All complaints must be submitted in writing and should be submitted within 180 days of when you knew or should have known that the alleged violation occurred.

14 We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protect health information. We are also to abide by the terms of the notice currently in effect. If you have any questions in reference to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number. By signing this Agreement, you are only acknowledging that you have received or been given the opportunity to receive a copy of our Notice of Privacy Practices. Signature: Date Print Name: Summary of Rights and Obligations Concerning Health Information Grove Spine & Sports Care is committed to preserving the privacy and confidentiality of your health information, which is required both by federal and state law, as well as by ethics of the medical profession. We are required by law to provide you with this notice of our legal duties, your rights, and our privacy practices, with respect to using and disclosing your health information that is created or retained by Grove Spine & Sports Care. Each time you visit us, we make a record of your visit. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. We have an ethical and legal obligation to protect the privacy of your health information, and we will only use or disclose this information in limited circumstances. In general, we may use and disclose your health information to: plan your care and treatment; provide treatment by us or others; communicate with other providers such as referring physicians; receive payment from you, your health plan, or your health insurer; make quality assessments and work to improve the care we render and the outcomes we achieve, known as health care operations; make you aware of services and treatments that may be of interest to you; and comply with state and federal laws that require us to disclose your health information. We may also use or disclose your health information where you have authorized us to do so. You have certain rights to your health information. You have the right to: ensure the accuracy of your health record; request confidential communications between you and your physician and request limits on the use and disclosure of your health information; and request an accounting of certain uses and disclosures of health information we have made about you. We are required to: maintain the privacy of your health information; provide you with notice, such as this Notice of Privacy Practices, as to our legal duties and privacy practices with respect to information we collect and maintain about you; abide by the terms of our most current Notice of Privacy Practices; notify you if we are unable to agree to a requested restriction; and accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations. We reserve the right to change our practices and to make the new provisions effective for all your health information that we maintain. Should our information practices change, a revised Notice of Privacy Practices will be available upon request. If there is a material change, a revised Notice of Privacy Practices will be distributed to the extent required by law. We will not use or disclose your health information without your authorization, except as described in our most current Notice of Privacy Practices.