Powell Chiropractic Clinic, Inc.

Transcription

1 Powell Chiropractic Clinic, Inc. Dr. James P. Powell Dr. James D. Powell Dr. Robert Powell Dr. Walter B. Null IV Dr. Abbey M. Crouse PATIENT REGISTRATION Date: / / Home Phone:( ) Work Phone: ( ) Cell : Patient: Last Name First Name Initial Street Address: City: State: Zip: Sex M F Age: Birth date: / / Single Married Widowed Separated Divorced Social Security #: - - Driver s License # Insured Name: Last Name First Name Initial How and where did you learn about this clinic? Relationship To Insured: Self Spouse Child Other Condition/Illness Related To: Illness Employment Auto Other Company Name Occupation EMPLOYER SPOUSE (PARENT) PATIENT INSURANCE INFORMATION SPOUSE & CO- INSURANCE INFORMATION Address City State Zip Phone ( ) Full-time Part-Time Name Last Name First Name Initial Birth date / / Social Security # - - Employer Name Occupation Address Phone ( ) City State Zip Please list any and all insurance and/or employee health care plan coverage you or your spouse have: Insurance Company or Health Care Plan Name Policy/Group #: Effective Date: Name of Insured: ID#: Please list any and all coinsurance and/or employee health care plan coverage you or your spouse have: Insurance Company or Health Care Plan Name Policy/Group #: Effective Date: Name of Insured: ID#:

2 MEDICAL INFORMATION Are your present symptoms or conditions related to or the result of an auto accident, workrelated injury or other personal injury someone else might be legally liable for? Yes No Your Initials If you answered yes, please fill out accident specific form, available at the front desk. Pregnant? Yes No Pacemaker? Yes No LEGAL INFORMATION Family Physician: Attorney Telephone: Address Person(s) to contact in case of emergency, questions concerning my treatment, and any questions concerning my account or account balance. Name Relationship Telephone # Cell Phone # LEGAL ASSIGNMENT OF BENEFITS AND RELEASE OF MEDICAL AND PLAN DOCUMENTS In considering the amount of medical expenses to be incurred, I, the undersigned, have insurance and/or employee health care benefits coverage with the above captioned, and hereby assign and convey directly to Powell Chiropractic Clinic all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for services rendered from such doctor and clinic. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize the doctor to release all medical information necessary to process this claim. I hereby authorize any plan administrator or fiduciary, insurer and my attorney to release to such doctor and clinic any and all plan documents, insurance policy and/or settlement information upon written request from such doctor and clinic in order to claim such medical benefits, reimbursement or any applicable remedies. I authorize the use of this signature on all my insurance and/or employee health benefits claim submissions. I hereby convey to the above named doctor and clinic to the full extent permissible under the law and under the any applicable insurance policies and/or employee health care plan any claim, chose in action, or other right I may have to such insurance and/or employee health care benefits coverage under any applicable insurance policies and/or employee health care plan with respect to medical expenses incurred as a result of the medical services I received from the above named doctor and clinic and to the extent permissible under the law to claim such medical benefits, insurance reimbursement and any applicable remedies. Further, in response to any reasonable request for cooperation, I agree to cooperate with such doctor and clinic in any attempts by such doctor and clinic to pursue such claim, chose in action or right against my insurers and/or employee health care plan, including, if necessary, bring suit with such doctor and clinic against such insurers and/or employee health care plan in my name but at such doctor and clinic's expenses. Should this assignment be prohibited in part or in whole under any anti-assignment provision of my policy/plan, please advise and disclose to my provider in writing such anti-assignment provision within 30 days upon receipt of my assignment, otherwise this assignment should be reasonably expected to be effective and such anti-assignment is waived. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I have read and fully understand this agreement. Signature Date / /

3 Powell Chiropractic Clinic, Inc. Dr. James P. Powell Dr. James D. Powell Dr. Robert Powell Dr. Walter B. Null IV Dr. Abbey M. Crouse The Practice: PRACTICE REQUIREMENTS (a) Is required by federal law to maintain the privacy of your Personal Health Information (PHI) and to provide you with this Privacy Notice detailing the Practice s legal duties and privacy practices with respect to your PHI. (b) Powell Chiropractic Clinic, Inc. adheres to Ohio law in those instances where Ohio law does not conflict with federal law. (c) Is required to abide by the terms of this Privacy Notice. (d) Reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice provisions effective for all of your PHI that it maintains. (e) Will distribute any revised Privacy Notice to you prior to implementation. (f) Will not retaliate against you for filing a complaint. EFFECTIVE DATE This Notice is in effect as of 04/15/03. If you would like to review our HIPPA agreement, please advise our staff and we will supply you with detailed information. PATIENT ACKNOWLEDGEMENT By subscribing my name below, I acknowledge that I have read this Notice, and that I understand and agree to its terms. Patient Name Patient Signature Please Initial: I am giving permission to leave a message on my home or cell phone: Yes No Date I am giving permission to leave a detailed message on my home or cell phone: Yes No

4 AUTO INSURANCE VERIFICATION FORM Name: Appointment Date: Powell Acct: AS PREVIOUSLY EXPLAINED TO YOU, OUR OFFICE POLICY IS TO BILL YOUR AUTO INSURANCE THROUGH THE MEDICAL CLAUSE IN YOUR POLICY. YOU MUST PROVIDE US WITH THE FOLLOWING INFORMATION: 1. DATE OF ACCIDENT: 2. YOUR AUTO INSURANCE INFORMATION: a. COMPANY NAME: b. ADJUSTER NAME: c. INSURANCE MAILING ADDRESS: d. INSURANCE TELEPHONE NUMBER: e. CLAIM #: 3. RESPONSIBLE PARTY INSURANCE INFORMATION a. COMPANY NAME: b. ADJUSTER NAME: c. INSURANCE MAILING ADDRESS: d. INSURANCE TELEPHONE NUMBER: e. CLAIM #:

5 ASSIGNMENT AND AUTHORIZATION PRIVATE AND GROUP ACCIDENT AND HEALTH INSURANCE (YOUR INSURANCE/AUTO-MED INFORMATION) I hereby my insurance company Name of Company to pay directly to POWELL CHIROPRACTIC CLINIC, INC., 4867 Munson Street, NW, Canton, Ohio the TOTAL AMOUNT OF MEDICAL CHARGES payable under the terms of Policy Number Claim Number, on claim commencing on or about. Date I specifically authorize that this assignment may be paid from disability benefits, medical payments, or from ANY benefits due to me under this claim. I understand and agree that any unpaid balances not covered by this policy will be paid by me. I also authorize the above named Doctor/Clinic to release any information, pertinent to my case, to any insurance company, adjuster or attorney involved in the case. Dated at Canton, Ohio this day of, 20. Signature of Policy Holder Witness I hereby state and agree that a photocopy of this document will be deemed as valid and binding on all parties involved as the original copy.

6 ASSIGNMENT AND AUTHORIZATION PRIVATE AND GROUP ACCIDENT AND HEALTH INSURANCE (RESPONSIBLE PERSON S INSURANCE) I hereby request Name of Company to pay directly to POWELL CHIROPRACTIC CLINIC, INC., 4867 Munson Street, NW, Canton, Ohio the TOTAL AMOUNT OF MEDICAL CHARGES payable under the terms of Policy Number Claim Number, on claim commencing on or about. Date I specifically authorize that this assignment may be paid from disability benefits, medical payments, or from ANY benefits due to me under this claim. I understand and agree that any unpaid balances not covered by this policy will be paid by me. I also authorize the above named Doctor/Clinic to release any information, pertinent to my case, to any insurance company, adjuster or attorney involved in the case. Dated at Canton, Ohio this day of, 20. Signature of Claimant if other than Policy Holder Witness I hereby state and agree that a photocopy of this document will be deemed as valid and binding on all parties involved as the original copy.

7 PATIENT VERIFICATION I have been advised by this Clinic that the preferred method for payment of treatment is for the fees to be paid directly by me as I receive treatment: I do not want my health insurance to be billed for treatment of my injuries, except in the case that my own liability insurer requires it as a condition to qualifying for medical payments coverage. I authorize this Clinic to bill my own liability insurer for treatment fees I incur. I authorize this Clinic to send notice of the Assignment to my own liability insurer, to the liability insurer of the person I claim caused my injuries, and to the attorney representing me for My Claim. This document is made a part of the Assignment I have signed in favor of the Clinic. Name of Liability Insurer for Person at Fault Name of My Liability Insurer Name of My Attorney If Applicable I have received a copy of an Assignment which I have signed in favor of this Clinic and Schedule of Treatment Fees. Signature of Patient, Parent or Legal Guardian Date Print or Type Name Staff Witness

8 PAYMENT FOR TREATMENT (When Patient's Health Insurance Will Not Be Billed) I have been injured. I do not have health insurance or do not want my health insurance to pay for the treatment fees. If my automobile insurance will cover my treatment fees, I authorize this Clinic to bill this insurer. Even if no other person is at fault for my injuries caused by an accident, agree to sign this Clinic's Assignment and related documents, and will provide any information required by the Clinic. I realize that any money which I receive from my automobile insurer for this Clinic's treatment fees must be immediately paid over to this Clinic. If I believe that one or more persons are at fault for causing my injuries in an accident, I agree to sign this Clinic's Assignment and related documents, and will provide any information required by the Clinic. I understand that my automobile insurer, or an insurer representing someone I believe to be at fault for causing my injuries, or that persons' attorney, or an attorney representing me in a claim for injuries, may request reports, copies of records may require a physician from this Clinic to provide deposition testimony or testimony in court, or other information. I understand and agree that I am financially responsible to this Clinic to pay the Clinic's costs for these items, and that the Clinic may request payment in advance for some or all of these items, even if this Clinic's Assignment states otherwise. I understand and agree that all of my records, including x-rays, are permanent records of this Clinic. I authorize the release of any information relevant to my treatment, including information regarding treatment fees, to insurers and attorneys who are involved with my claim and their respective representatives. I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND IT. THIS DOCUMENT IS PART OF THE ASSIGNMENT I HAVE SIGNED IN FAVOR OF THE CLINIC. I HAVE RECEIVED A COPY OF THIS DOCUMENT. Signature of Patient Date Print or Type Patient s Name Signature of Parent or Legal Guardian

9 ASSIGNMENT I was involved in an accident on or around [date] in which I was injured and for which I have or may have a claim against another person(s) for causing my injuries, including who is insured by. In consideration of the agreement of Powell Chiropractic Clinic Inc. (referenced as the "Clinic") to delay billing me personally for medical treatment rendered until resolution of This Claim: Copyright 1999 John P. Lowry, Esq. Boehm, Kurtz & Lowry, Attorneys at law 1. I now assign, without any right to later revoke a part of any proceeds from my claim equal to the fees incurred by me to this Clinic for all treatment and other services rendered by this Clinic. I am not assigning any legal cause of action in this Claim, but only prospective proceeds. I also assign to the Clinic my right to enforce the obligation of any insurance company to pay settlement proceeds for any settlement agreement made by or for me in exchange for my signing such insurance company's release of claim. Prior to settlement or other disposition of this claim, I understand and permit the Clinic to pursue payment from any source other than me personally, including medical payments covered in an automobile liability policy. 2. This Assignment and related documents which I have signed in connection with it states the entire agreement and my complete understanding regarding the Clinic's fees. I have not relied on any statements by the Clinic or the Doctor or other information before making this Assignment. I understand that I remain responsible for any Clinic fees not paid out of this Claim. Signature of Patient 3. I understand that it is my responsibility during treatment to remain aware of my cumulative account balance for services rendered. I have received a schedule of treatment fees for this Clinic, or if I have not, will request this Clinic for one in writing. 4. I understand that this is an express contract to pay for the services rendered by this Clinic. I agree to pay my account balance in full and/or direct its payment from My Claim proceeds regardless of whether any other person or entity attempts to or fails to fully reimburse me for it. If I dispute my account balance or treatment rendered, I agree that my remedy will be to resolve it with a separate action from My Claim. 5. NOTICE: I DIRECT ANY INSURANCE COMPANY, ATTORNEY, OR OTHER PERSON WHO HOLDS OR LATER HOLDS ANY PROCEEDS FROM THIS CLAIM TO APPLY ANY PROCEEDS FROM THIS CLAIM TO MY TOTAL ACCOUNT BALANCE OUT OF THE TOTAL PROCEEDS HELD IN MY BEHALF, UNLESS THE CLINIC CONFIRMS PRIOR PAYMENT OF IT IN WRITING. "TOTAL PROCEEDS" HELD BY AN ATTORNEY FOR THIS CLAIM SHALL MEAN PROCEEDS AFTER DEDUCTION OF ATTORNEY FEES. 6. This Assignment is governed by Ohio law. Jurisdiction shall be in Ohio, and venue shall lie in the county in which the Clinic is located, unless required by applicable law to lie in a different county than which I reside. 7. I REALIZE THAT I HAVE NOW GIVEN AWAY A PART OF ANY PROCEEDS FROM THIS CLAIM. IF I RECEIVE ANY PROCEEDS FROM THIS CLAIM, I AGREE TO IMMEDIATELY DETERMINE IF THIS CLINIC HAS BEEN SEPARATELY PAID IN FULL. UNLESS THE CLINIC CONFIRMS FULL PAYMENT IN WRITING, I REALIZE THAT ANY USE BY ME OF THESE PROCEEDS IS TAKING OR CONVERTING MONEY THAT IS THE PROPERTY OF THIS CLINIC. 8. I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND IT. Name of Person at Fault Signature of Patient Date Print or Type Patient s Name This Assignment Has Been Signed On The Clinic Premises: Signature of Parent or Legal Guardian Staff Witness

10 UPDATED PATIENT INFORMATION We are in the process of updating our records to comply with federal standards, please answer the following questions: Patient: Date: Last Name First Name Initial Preferred Language? English Spanish Other Race? I do not wish to provide this information. White American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Black or African American Asian Other Ethnicity? I do not wish to provide this information. Non-Hispanic or Non-Latino Hispanic or Latino Other Smoking Status? Current every day smoker: How many packs/day? Current some day smoker: How many packs/week? Former smoker Never smoker Do you have any medication allergies? No known medication allergies Yes. What? Are you currently taking any medications (prescription or over-the-counter)? Not currently taking any medications Yes What? What? What? mg mg mg

11 Patient Name: Do you take vitamins or other supplements? Not currently taking any vitamins or supplements Yes What? What? What? mg or times/day mg or times/day mg or times/day Have you had recent tests showing high cholesterol and/or triglycerides? Yes No Have you had recent tests showing high blood pressure? Yes No Are you diabetic? Yes No Are you taking insulin? Yes No Do you eat breakfast daily? Yes No How many days/week do you skip one or more meals? or more How many servings of vegetables do you eat/day (average)? or more How many servings of fruit do you eat/day (average)? or more How many times do you eat fast-food or refined/processed foods a week (average)? or more What are your average hours of sleep/night? or more Do you need to take pills to sleep or be able to relax? Yes No Have you received the full, standard profile of vaccinations? Yes No Have you had the flu shot this year? Yes No Have you had flu shots in the past? Yes No

12 NECK DISABILITY INDEX QUESTIONNAIRE LAST NAME: FIRST NAME: MI: Date: This questionnaire is designed to help us better understand how your neck pain affects your ability to manage everyday life activities. Please mark the one that most closely describes your present day situation in each section. SECTION 1 - PAIN INTENSITY SECTION 6 CONCENTRATION I have no pain at the moment. I can concentrate fully without difficulty. The pain is very mild at the moment. I can concentrate fully with slight difficulty. The pain is moderate at the moment. I have a fair degree of difficulty concentrating. The pain is fairly severe at the moment. I have a lot of difficulty concentrating. The pain is very severe at the moment. I have a great deal of difficulty concentrating. The pain is the worst imaginable at the moment. I can't concentrate at all. SECTION 2 - PERSONAL CARE (Washing, Dressing,etc.) SECTION 7 WORK I can look after myself normally without causing extra I can do as much work as I want. pain. I can look after myself normally, but it causes extra pain. I can only do my usual work, but no more. It is painful to look after myself, and I am slow and I can do most of my usual work, but no more. careful. I need some help but manage most of my personal care. I can't do my usual work. I need help every day in most aspects of self -care. I can hardly do any work at all. I do not get dressed. I wash with difficulty and stay in bed. I can't do any work at all. SECTION 3 LIFTING SECTION 8 DRIVING I can lift heavy weights without causing extra pain. I can drive my car without neck pain. I can lift heavy weights, but it gives me extra pain. I can drive as long as I want with slight neck pain. Pain prevents me from lifting heavy weights off the floor I can drive as long as I want with moderate neck pain. but I can manage if items are conveniently positioned, ie. on a table. Pain prevents me from lifting heavy weights, but I can I can't drive as long as I want because of moderate neck manage light weights if they are conveniently positioned. pain. I can lift only very light weights. I can hardly drive at all because of severe neck pain. I cannot lift or carry anything at all. I can't drive my car at all because of neck pain. SECTION 4 READING SECTION 9 SLEEPING I can read as much as I want with no neck pain. I have no trouble sleeping. I can read as much as I want with slight neck pain. I can read as much as I want with moderatee neck pain. I can't read as much as I want because of moderate neck pain. I can't read as much as I want because of severe neck pain. I can't read at all. SECTION 5 HEADACHES I have no headaches at all. I have slight headaches that come infrequently. I have moderate headaches that come infrequently. I have moderate headaches that come frequently. I have severe headaches that come frequently. I have headaches almost all the time. My sleep is slightly disturbed for less than 1 hour. My sleep is mildly disturbed for up to 1-2 hours. My sleep is moderately disturbed for up to 2-3 hours. My sleep is greatly disturbed for up to 3-5 hours. My sleep is completely disturbed for up to 5-7 hours. SECTION 10 RECREATION I have no neck pain during all recreational activities. I have some neck pain with alll recreational activities. I have some neck pain with a few recreational activities. I have neck pain with most recreational activities. I can hardly do recreational activities due to neck pain. I can't do any recreational activities due to neck pain.

13 REVISED OSWESTRY DISABILITY INDEX QUESTIONNAIRE LAST NAME: FIRST NAME: MI: Date: Please select one answer for each question: Section 1 - Pain Intensity The pain comes and goes and is very mild. The pain is mild and does not vary much. The pain comes and goes and is moderate. The pain is moderate and does not vary much. The pain comes and goes and is severe. The pain is severe ad does not vary much. Section 2 -- Personal Care (Washing, Dressing, etc.) I would not have to change my way of washing or dressing in order to avoid pain I do not normally change my way of washing or dressing even though it causes some pain. Washing and dressing increases the pain, but I manage not to change my way of doing it. Washing and dressing increases the pain and I find it necessary to change my way of doing it. Because of the pain, I am unable to do some washing and dressing without help. Because of the pain, I am unable to do any washing or dressing without help. Section 3 Lifting I can lift heavy weights without extra pain. I can lift heavy weights but it gives extra pain. Pain prevents me from lifting heavy weights off the floor Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, for example on a table. Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned. I can only lift very light weights, at the most Section 4 Walking Pain does not prevent me from walking any distance. Pain prevents me from walking more than one mile. Pain prevents me from walking more than ½ mile. Pain prevents me from walking more than ¼ mile I can only walk using a cane or crutches I am in bed most of the time and have to crawl to the toilet. Section 6 Standing (Remember, standing is NOT walking.): I can stand as long as I want without pain. I have some pain while standing, but it does not increase with time. I cannot stand for longer than 1 hour without increasing pain. I cannot stand for longer than ½ hour without increasing pain. I cannot stand for longer than 10 minutes without increasing pain. I avoid standing, because it increases the pain straight away. Section 7 -- Sleeping I get no pain in bed. I get pain in bed, but it does not prevent me from sleeping well. Because of pain, my normal night s sleep is reduced by less than one than one quarter. Because of pain, my normal night s sleep is reduced by less than one half. Because of pain, my normal night s sleep is reduced by less than one than three-quarter. Pain prevents me from sleeping at all. Section 8 Social Life My social life is normal and gives me no pain. My social life is normal but increases the degree of pain. Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g. dancing,etc. Pain has restricted my social life and I do not go out as often. Pain has restricted my social life to my home. I have hardly any social life because of pain. Section 9 Traveling I get no pain while traveling. I get some pain while traveling, but none of my usual forms of travel make it any worse. I get extra pain while traveling, but it does not compel me to seek alternative forms of travel. I get extra pain while traveling which compels me to seek alternative forms of travel. Pain restricts me for all forms of travel. Pain prevents all forms of travel except that down lying down. Section 5 Sitting ( Favorite chair includes a recliner.): Section 10 Changing Degree of Pain I can sit in any chair as long as I like without pain. My pain is rapidly getting better. I can only sit in my favorite chair as long as I like My pain fluctuates but overall is definitely getting better. Pain prevents me from sitting more than one hour. My pain seems to be getting better but improvement is slow at the present. Pain prevents me from sitting more than ½ hour. My pain is neither getting better nor worse. Pain prevents me from sitting more than 10 minutes. My pain is gradually worsening. Pain prevents me from sitting My pain is rapidly worsening.