PATIENT INFORMATION DATE FIRST NAME LAST NAME ADDRESS STREET CITY STATE ZIP HOME ( ) WORK ( ) EXT. CELL ( ) BIRTH DATE / / AGE SS# - - MARITAL STATUS: S M. D. W PERSON RESPONSIBLE FOR ACCOUNT: OCCUPATION: EMPLOYER: CDL#: EMAIL: REFERRED BY: INSURANCE INFORMATION IS PATIENT INSURED? YES NO INSURANCE COMPANY S NAME: INSURANCE ID #: INSURANCE GROUP ID #: INSURED S NAME IF NOT PATIENT: PATIENT S RELATIONSHIP TO INSURED: DOES PATIENT HAVE OTHER HEALTH INSURANCE? *PAYMENT IS EXPECTED AT TIME OF VISIT UNLESS PRIOR ARRANGEMENTS HAVE BEEN MADE. *WE ACCEPT ALL MAJOR CREDIT CARDS FOR YOUR CONVENIENCE. 2737 CAMPUS DRIVE, IRVINE, CA 92612 949.476.1250
Please Mark Your Areas Of Pain On The Figures Shown Below PATIENT SYMPTOMS : *Patient s Present Symptoms: *Any Medication Being Taken? Yes { } No { } * If Yes, Please Name Medication? *Date of Last Physical? *Recent Falls? *Surgery Date? *First Chiropractic Treatment: Yes { } No { } *Patient s Comments: Check Symptoms You Have Noticed: { }Headache { }Dizziness { }Light Hurt Eyes { } Diarrhea { }Neck Pain { }Head Seems Heavy { }Loss of Memory { } Feet Cold { }Neck Stiff { }Pins/Needles-Arms { }Ears Ring { } Hands Cold { }Sleeping Problem { }Pins/Needles-Legs { }Face Flushed { } Stomach Upset { }Back Pain { }Numbness in Fingers { }Buzzing in Ears { } Constipation { }Nervousness { }Numbness in Toes { }Loss of Balance { } Cold Sweats ( }Tension { }Shortness of Breath { }Fainting { } Fever { }Irritability { }Fatigue { }Loss of Smell { } High Blood Pressure { }Chest Pain { }Depression { }Loss of Taste Additional Symptoms: Patient s First Name: _ Last Name:
INFORMED CONSENT FOR CHIROPRACTIC TREATMENT PHYSICAL THERAPY, MOVEMENT THERAPY AND CARE I hereby request and consent to chiropractic adjustments and chiropractic procedures, including various modes of physiotherapy and diagnostic x-rays on me (or on the patient named below, for whom I am legally responsible) by the doctor, Physical Therapist or Movement Therapist affiliated with Performance Health & Wellness. I understand that, as in the practice of medicine, in the practice of chiropractic care, there are some risks to treatment, including but not limited to, fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications. I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based on the facts then known, is in my best interests. I have read, or have had to read to me, the above consent. By signing below, I agree to the above and allow the doctor or intern affiliated with Performance Health & Wellness to perform such. I intend this consent form to cover the entire course of treatment for my present condition and for any future conditions(s) for which I seek treatment. Employee Witness Patient s Signature/ or Guardian 2737 Campus Dr. Irvine, CA 92612 949.476.1250
Acknowledgement & Understanding In hereby acknowledge that I am receiving (or about to receive) health care services at Performance Health & Wellness and that I have been advised that the doctor(s) providing the services is/are willing to wait for payment for these services provided that there continues to be a reasonable change that payment will be made either by insurance proceeds or out of the settlement of a liability claim I understand that if it is determined either: A. That there is no insurance company obligated to pay for the services, or if the insurance company involved refuses to acknowledge an assignment to the doctor(s) or make other provisions for the protection of the interest of the doctors(s); or B. If a liability claim exists, and my attorney refuses to agree to protect the interest of the doctor(s), or if I have not engaged the services of an attorney; then payment for services rendered by the doctors at (Company s Name) will be made on a current basis and my bill paid in full as soon as my liability claim is settled or the passage of three months from my last treatment, whichever occurs first. Dated Day of, 20 (Month) (Day) (Year) Patient s Signature/ or Guardian Employee Witness 2737 Campus Dr. Irvine, CA 92612 949.476.1250
OFFICE POLICY REGARDING BILLING PROCEDURES 1. Please verify your insurance coverage, call your agent, personnel director, or insurance company. Our office DOES NOT guarantee that your insurance company will pay. 2. Deductible and co-payment are due at the time of service. 3. A 12% annual finance charge will be assessed on accounts 30 days past due. 4. You are required to sign an AUTHORIZATION TO PAY PHYSICIAN or a BENEFITS ASSIGNED FORM and any other assignment documents required by your insurance company on your first office visit. 5. Since by taking your insurance and assignment, we have to wait for payment, this courtesy may be withdrawn if circumstance warrant it. 6. Your insurance should pay within 30 working days. If your insurance has not paid within 60 days, you must pay the balance due and be reimbursed by your insurance company when and if it pays. 7. We require that You notify us 24 Hours in Advance as to any Appointment Changes. There will be a 50% Late Cancellation Fee, 100% Charge For NO SHOW. We only ask for the courtesy of a phone call so that we may give your appointment time to another in need. Missed appointments are not billed to insurance. 8. We will bill your PRIMARY INSURANCE ONLY. If you have secondary insurance coverage, we will provide the information needed for you to bill. 9. Our office will NOT enter into a dispute with your insurance company over your claim. This is your responsibility and obligation. 10. You will receive a monthly statement that will reflect your balance. 11. Services are due and payable at the time they are rendered unless other arrangement are made. 12. If you understand the above office policies, please sign your name below. Employee Witness Signature of Patient/ or Guardian 2737 Campus Dr. Irvine, CA 92612 949.476.1250
DHHS, OFFICE OF CIVIL RIGHTS 200 INDEPENDENCE AVENUE, S.W. ROOM 500F HHH BUILDING WASHINGTON, DC 20201 This Notice Is Effective As of Month Day Year I have read the Privacy Notice and Understand My Rights Contained in the Notice. By way of my signature, I proved Performance Health & Wellness with my authorization and consent to use and disclosed my protected health care information for the purposes of treatment, payment and health care operations described in the Privacy Notice. Patient s Signature/or Guardian Authorized Facility Signature