HONEOYE FALLS FAMILY CHIROPRACTIC 14 WEST MAIN STREET, HONEOYE FALLS, NY FAX:

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1 HONEOYE FALLS FAMILY CHIROPRACTIC 14 WEST MAIN STREET, HONEOYE FALLS, NY FAX: If this injury/condition is a worker s compensation case or related to an auto accident please inform the receptionist at this time. Name _ First MI Last Address City State Zip Phone (H) (W) (cell) Date of Birth Age SS # Sex: M / F Marital Status: S / M / Oth Number of children _ Contact in case of emergency Phone _ Referred to this office by address (optional) Employer _ Occupation Address City State Zip Primary Physician Phone # Health Insurance (Please have insurance card available) ID # _ Insured s Date of Birth I understand and agree all services rendered to me are charged directly to me and I am responsible for payment. I will also be responsible for any collection or attorney s fees due. However, I authorize the doctor s office to release any information in my records that will assist me in making collection from the insurance carrier and any amount authorized to be paid directly to the doctor will be credited to my account upon receipt. Patient Signature _ Date (or parent if a minor) Relationship to Patient

2 Reason for visit Please list other Doctors/Therapists seen for this condition: Any x-rays taken of the area of complaint? Yes or No If yes, then where? Rochester Radiology Associates, Borg Imaging Group, Ide Group, Hospital Other Have you had recent or major surgery or illness? Yes or No Please describe Do you smoke? Yes or No If yes, packs/day for years Female: Are you pregnant? Yes or No Are you taking birth control? Are you taking any blood thinners? Are you right or left handed? Family History: S=self M=mother F=father G=grandparent (Please check all that apply) Diabetes Sleep problems Migraine headaches Cancer Liver disease High blood pressure Arthritis Kidney disease Asthma Osteoporosis Heart disease AIDS/HIV Back problems Stroke Prostate problem Neck problems Pace maker Thyroid problems

3 NAME _ DATE 1. Please list ALL medications including dosage that you are currently taking. Onset Date Medication Condition Prescribed For Dosage (if known) Resolve Date 2. Please list anything you are allergic to. (including medications) 3. Have you had any recent falls or accidents? Yes No If yes, please explain. 4. Please list ANY current health problems that you have. Onset Date Condition 5. Please list any resolved health problems you have had. (cancer, sprains/strains, etc.) Resolved Date Condition Honeoye Falls Family Chiropractic, PC 14 West Main Street, Honeoye Falls, NY fax [Type text]

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5 INFORMED CONSENT I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including soft tissue work and deep tissue work (neuromuscular re-education), massage cupping, physical therapy modalities, neuro-emotional technique, muscle testing, electric stimulation, ultrasound, acoustical massage, exercise and rehabilitation, nutrition and homeopathic remedies and ear candling by the doctor of chiropractic named below and/or other licensed doctors of chiropractic who now or in the future treat me while employed by, working or associated with or serving as back-up for the doctor of chiropractic named below and other therapists, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I have had an opportunity to discuss with the doctor of chiropractic named below and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and procedures. I understand that results vary and no specific outcome is guaranteed. I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment, including, but not limited to, fractures, disc injuries, strokes, dislocations and sprains and emotional releases. I do not expect the doctor to be able to anticipate and explain all possible risks and complications, and I wish to rely on the doctor to exercise his judgment during the course of the procedure in the manner which the doctor believes, based upon the facts then known, is in my best interests. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. Patient Name Patient Signature (or patient representative indicate if signing for patient) Date Brian D. Kaufman, DC Date Honeoye Falls Family Chiropractic, PC 14 West Main Street, Honeoye Falls, NY fax [Type text]

6 BRIAN D. KAUFMAN, DC HONEOYE FALLS FAMILY CHIROPRACTIC, PC 14 W. Main St, Honeoye Falls, NY fax Notice of Patient Privacy Rights THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This office is committed to protecting your personal medical information. The creation of a record detailing the care and services you receive helps this office to provide you with quality health care and complies with this office s medical records retention requirements. This notice applies to the medical records maintained by this office and it specifically details the ways in which your medical information may be used and disclosed to third parties. This notice also details your individual rights regarding your medical records. 1. This office may use and/or disclosure your medical information for the purposes of: a. Treatment In order to provide you with the healthcare you require, this office will provide your medical information to those healthcare professionals, whether on this office s staff or not, directly involved in your care so that they may understand your medical condition and needs. For example, a physician treating you for lower back pain may need to know about the results of your latest physical examination by our office. b. Payment In order to get paid for services provided, this office will provide your medical information, directly or through a billing service, to appropriate third part payors, pursuant to their billing and payment requirements. For example, this office may need to provide the Medicare program with information about the services you received so that this office can be properly reimbursed. This office may also need to tell your insurance plan about a treatment you are going to receive so that it can be determined whether or not your plan will cover the treatment. c. Healthcare Operations In order to gain an overall view of various elements of this office s operations, individual medical information may be collected, compiled & disseminated. For example, this office may utilize your medical information in order to evaluate the performance of our personnel in providing care to you. 2. This office may use and/or disclose your medical information, without a written consent from you, in the following instances: a. De-identified Information Information that is not individually identifiable or that has had all personally identifying information removed, in accordance with applicable laws, may be freely disclosed by this office. This office may use patient testimonials and display pictures of patients with written consent without removing personal identifiers. b. Business Associate If this office obtains satisfactory written assurance from the business associate, in accordance with applicable laws, that the business associate will appropriately safeguard the protected information. A business associate is an entity that assists this office in undertaking some essential function, such as a billing company that assists the office in submitting claims for payment to insurance companies or other payers; others involved with your overall healthcare: i.e. massage therapists, nutritional professionals, personal trainers; c. Personal Representative If under applicable New York law a person has the authority to represent you in making decisions related to your health care, information may be disclosed to that person without your written consent; d. This office will call patients by name for appointments and may or may not have a sign in sheet. e. Emergency Situations For the purpose of obtaining or rendering emergency treatment to you, if the office attempts to obtain your consent but is unable to do so; To a public or private entity authorized by law or by its charter to assist in disaster relief efforts, for the purpose of coordinating your care with such entities in an emergency situation; f. Communication Barriers If, due to substantial communication barriers or inability to communicate with you, this office has been unable to obtain your consent and this office determines, in the exercise of its professional jusgement, that your consent to receive treatment is clearly inferred from the circumstances; g. Directory In order to maintain a directory of individuals in this office, their location and their condition in non-specific general terms. h. Involvement in Care or Payment -- In accordance with applicable laws, disclosure may be made to your family member, other relatives, close personal friends and/or any other person identified by you, of such information that is relevant to the person s involvement with your care or payment related to your health care; i. Notification In order to notify or assist in the notification of a family member, a personal representative or another person responsible for your care of your location or general condition; j. Required by Law When and to the extent that such disclosure is required by law, complies with and is limited to the relevant requirements of such law; k. Criminal Conduct To a law enforcement official, that this office believes in good faith contributes evidence of criminal conduct that occurred on the office premises; l. Threat to Health and/or Safety If it is necessary to prevent or lessen a serious and imminent threat to the health and/or safety of a person or the public, in accordance with applicable laws; m. Appointment Reminders, Treatment Alternatives and Health Related Benefits In order to provide you with appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you. This office will send a postcard and/or call your home and/or leave a message on your answering machine or with any individual answering the phone as a reminder of your scheduled appointment with this office; n. Military and Veterans If you are a member of the armed forces, as required by military command authorities; [Type text]

7 o. Workers Compensation In order to provide information about you to workers compensation programs designed to provide benefits for work-related injuries; p. Public Health Risks In order to prevent or control disease, injury and disablitiy and to report child abuse or neglect; q. Health Oversight Activities In order to provide information to a health oversight agency, such as the New York State Department of Health, for activities authorized by law, including inspections, investigations, audits and licensure; r. Lawsuits and Disputes In order to comply with a court or administrative order in connection with a lawsuit or dispute; s. Coroners, Medical Examiners and Funeral Directors In order to provide information to a coroner, medical examiner or funeral director for purposes of identification of an individual, the determination of the cause of death and for burial purposes; and t. National Security and Intelligence Activities In order to provide authorized governmental officials with necessary intelligence information for national security activities and purposes authorized by law. 3. Other uses and/or disclosures will be made only with your written authorization and you may revoke any authorization as set forth in this notice. 4. Your Individual Rights You have the right to: a. Revoke any authorization and/or consent, in writing, at any time To request a revocation, please submit a written request to this office s Compliance Officer, as set forth in Section 4(i) below; b. Request restrictions on certain uses and/or individuals or entities to whom we may make disclosures as provided by law; however, this office is not obligated to agree to any requested restrictions To request restrictions, please submit a written request to this office s Privacy Officer, as set forth in Section 4(i) below. In your written request, you must inform this office what information you want to limit, whether you want to limit this office s use or disclosure, or both, and to whom you want the limits to apply. If this office agrees to your request, we will comply with the request unless the information is needed in order to provide you with emergency treatment; [Type text] Notice of Patient Privacy Rights (page 2) c. Receive confidential communications of protected health information as required by law To request confidential communications, you must make your request in writing to this office s Privacy Officer, as set forth in Section 4(i) below. We will accommodate all reasonable requests. Your request must specify how and where you wish to be contacted; d. Inspect and copy protected health information as provided by law This right includes access to medical and billing records. To inspect and copy health information, please submit a written request to this office s Privacy Officer, as set forth in Section 4(i) below. This office can charge you a fee for the costs of copying, mailing or other supplies associated with your request. This office may deny you access to medical information but have the right to have this denial reviewed as will be set forth more fully in the written denial notice; e. Amend incorrect or incomplete protected information as provided by law To request an amendment, please submit a written request to this office s Privacy Officer, as set forth in Section 4(i) below. You must provide a reason that supports your request for the amendment(s). This office may deny your request if it is not in writing, if you do not provide a reason in support of your request, if the information to be amended was not created by this office (unless the individual or entity that created the information is no longer available), if the information is not part of the medical information maintained by the office, if the information is not part of the information you would be permitted to inspect and copy, and/or if the information is accurate and complete; f. Receive an accounting of disclosures (but not the uses) of protected information as provided by law To request an accounting, please submit a written request to this office s Privacy Office, as set forth in Section 4(i) below. The request must state a time period which may not be longer than 6 years and may not include dates before April 14, The request should indicate in what form you want the list (such as a paper or electronic copy). The first list you request within a 12 month period will be free but this office may charge you for the costs of providing additional lists. This office will notify you of the costs involved and you can decide to withdraw or modify your request before any costs are incurred; g. To receive a paper copy of ths notice from this office upon request to the office s Privacy Officer, as set forth in Section 4(i) below; h. To complain to this office or to the Secretary of HHS if you believe your privacy rights have been violated to file a complaint, please contact this office s Privacy Officer, as set forth in Section 4(i) below. All complaints must be in writing; and i. To obtain more information on, or have your questions about your rights answered, you may contact this office s Compliance/Privacy Officer, at or via at mrcrackit@juno.com. 5. Office Rights & Requirements This office: a. Is required by law to maintain the privacy of protected health information and to provide individuals with notice of its legal duties and privacy practices with respect to protected information; b. Is required to abide by the terms of this notice; c. Reserves the right to change the terms of this notice and to make the new notice provisions effective for all protected information that it maintains; d. Will: i. Make available to all patients any revised notice prior to implementation; and ii. Give to you, and you will be required to sign a receipt for, any revised notice. e. Will not retaliate against you for filing a complaint 6. This original notice is in effect as of By signing a copy of this Notice, you will certify that you have received and reviewed this notice and that all of your questions have been answered to your satisfaction in language that you can understand. Print Name Signature Date (or parent if patient is a minor)

8 HONEOYE FALLS FAMILY CHIROPRACTIC, PC Signature on File and Payment Policies I authorize use of this form on all my insurance submissions. I authorize release of information to all my insurance companies (Worker s Compensation, No- Fault Carrier, Blue Cross/Blue Shield, Other ). I understand I am responsible for my bill in case of a denial or partial payment from above carrier. I understand I am responsible for any deductibles or co-payments as indicated at the time of my appointment. (deductible co-pay ) I authorize payment directly to my doctor. I permit a copy of this authorization to be used in place of the original. I understand that missed appointments and appointments cancelled with less than 24 hours notice may be charged $30.00 Name (please print) ID# Signature Date (or parent if minor) Honeoye Falls Family Chiropractic, PC 14 West Main Street, Honeoye Falls, NY fax [Type text]

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10 HONEOYE FALLS FAMILY CHIROPRACTIC PATIENT NAME: Age Height Weight Pulse Blood pressure Is there any motion that is painful? Yes No If yes, describe in detail: If you touched your right and left leg in many spots, are there any areas that don t feel the same? Yes No If yes, where? If you touched your right and left arm in many spots, are there any areas that don t feel the same? Yes No If yes, where? Has anyone ever said you have a short leg? Yes No If yes, which one? Right Left How much? How did they measure? Do you wear orthodics? Yes No If yes, why? For how long? Are they helping? Yes No Who made them for you? Do you have any muscle weakness? Yes No If yes, which ones?_ When your reflexes are checked is there anything unique about them? Describe in detail Would you be more comfortable if we ordered x-rays before I treat you? Yes No When did this problem become apparent? What makes feel better? (ex. ice, heat, specific stretch, nothing, rest, standing, sitting, Ibuprofen) What makes it worse? (ex. going up stairs, worse in am, sneezing, ice, stress, sleeping) Describe the quality (ex.achy, sharp, tight, dull, feels like broken glass, achy most of the time and sharp when I move quickly) Does the pain or symptoms go into your legs, feet, hands or arms? Yes No Be specific, for example The last 3 fingers on my right hand but only on the palm side On a scale of 1-10 (ten is the worst and one is no pain), choose a number that describes your pain right now Is the pain constant or does it come and go?