WELCOME TO WINDROSE CHIROPRACTIC Please complete the following information. We appreciate your cooperation! Chiropractic Case History/Patient Information (Please print) Date: Patient # Doctor Name: Social Security #: Address: City: Zip: Home #: Email: (By giving us your email address, you allow us to add you to our emailing list. We promise not to abuse the privilege.) Cell #: Fax #: Age: Birth Date: Race: Marital Status: M S W D Number of Children: Occupation Employer: Employer s Address: Office #: Spouse: Occupation: Employer: Name of Nearest Relative: Address: Phone #: Family Medical Doctor: Purpose of this appointment: How were you referred to our office? Page 1 of 9
1. What is your major symptom? 2. If this is a recurrence, when was the first time you noticed this problem? How did it originally occur? Has it become worse recently? Yes No Same Better Gradually Worse If worse, when and how? 3. How frequent is the condition? Constant Daily Intermittent Night Only How long does it last? All Day Few Hours Minutes 4. Are there any other conditions or symptoms that may be related to your major symptom? Yes No If yes, describe Are there other unrelated health problems? Yes No If yes, describe 5. Describe the pain: Sharp Dull Numbness Tingling Aching Burning Stabbing Other 6. Is there anything you can do to relieve the problem? Yes No If yes, describe If no, what have you tried to do that has not helped? 7. What makes the problem worse? Standing Sitting Lying Bending Lifting Twisting Other 8. Have you had any broken bones? Yes No If yes, please list and give dates: 9. List any major accident you have had other than those that might be mentioned above: 10. To your knowledge, have you had any diseases, major illnesses, or injuries not indicated on this form either in the past or the present? Yes No If yes, please explain: WOMEN ONLY: Are you pregnant or is there any possibility you may be pregnant? Yes No Page 2 of 9
Date symptoms appeared or accident happened: 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: What surgeries have you had? Please include dates: Have you been treated for any health conditions by a physician in the last year? Yes No If yes, describe: What medications or drugs are you taking? Please check any and all insurance coverage that may be applicable in this case: Major Medical Worker s Compensation Medicaid Medicare Auto Accident Other Name of Primary Insurance Company: Name of Secondary Insurance Company: AUTHORIZATION AND RELEASE: I authorize payment of insurance benefits directly to the 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. Patient s Signature Date: Guardian s Signature Authorizing Care: Date: Page 3 of 9
Windrose Chiropractic 20423 Kuykendahl, Suite 400 Spring, Texas 77379 832-717-0855 SPECIFIC AND IRREVOCABLE ASSIGNMENT OF BENEFITS To: Windrose Chiropractic 1. You are authorized to release any information you deem appropriate concerning my health condition to any insurance company, attorney or adjuster in order to process any claim for reimbursement of charges incurred at Windrose Chiropractic. 2. I authorize and assign the direct payment to you of any sum I now or hereafter owe you by my attorney out of the proceeds of any settlement of my case, and by any insurance company obligated to reimburse me for the charges for your services or otherwise obligated to make payment to me or you based in whole or in part upon the charges made for your services. 3. I give direct assignment against any claims against a third party whose negligence may have caused the patient s injury, up to the amount of the bill for treatment. 4. In the event any insurance company obligated by contractual agreement to make payment to me or to you for the charges made for your services refuses to make such payment upon demand by you, I hereby assign and transfer to you the cause of action that exists in my favor against any such company (the name(s) of which is believed to be correctly set forth under pertinent data below) and authorize you to prosecute said action either in my name or your name as you see fit and further authorize you to compromise, settle or understand that until all company (or companies) contractually obligated, you will refrain from attempts and efforts to collect the amount owed direct from me. I understand that whatever amounts you do not collect from insurance proceeds (whether it be all or part of what is due) I personally owe you. 5. I waive the Statute of Limitations regarding my doctor s right to recover. Date: Signed: Witness: Pertinent Data: Date of injury: Policy #: Name of Insurance: Page 4 of 9
LETTER OF NO ACCIDENT OR INJURY I hereby state with my signature that I was not involved in any auto accident, slip and fall, or work injury. My treatment is in no way associated with any 3 rd party, and no other party is responsible or liable for the cost of my treatment. Please process and pay all claims immediately. Sincerely, Patient Signature Date WINDROSE CHIROPRACTIC Massage therapy is offered in our clinic. Some insurance companies cover therapy; however, our therapists are not contracted with any insurance companies. Therefore, the charges will not be filed by our office. If you choose to file, a letter of medical necessity can be obtained and your company may reimburse you for a portion of the charges. We apologize for any inconveniences this may cause you. Patient s signature: Page 5 of 9
Windrose Chiropractic 20423 Kuykendahl Rd., Ste. 400 Spring, TX 77379 Phone (832) 717-0855 Fax (832) 717-7621 Angela D. Kropik, D.C. Lance G. Richardson, D.C. Disclosure of Fees 99203 Intermediate Initial History and Exam $80.00 99204 Comprehensive History and Exam $153.00 99212 Brief Office Visit $46.00 99213 Limited Office Visit $61.00 99214 Intermediate Office Visit $94.00 98940 Manipulation (1 2 areas) $45.00 98941 Manipulation (3 4 areas) $50.00 97014 Interferential Muscle Stimulation $21.00 97035 Ultrasound $25.00 97810 Acupuncture $65.00 9712452 Therapeutic Massage (15 min.) $30.00 97124 Therapeutic Massage (30 min.) $45.00 9712422 Therapeutic Massage (45 min.) $60.00 9712423 Therapeutic Massage (60 min.) $75.00 97530 Therapeutic Activities (15 min.) $40.00 975302 Therapeutic Activities (30 min.) $80.00 975303 Therapeutic Activities (45 min.) $120.00 975304 Therapeutic Activities (60 min.) $180.00 97110 Therapeutic Exercises (15 min.) $40.00 Average Billed Per Treatment $71.00 I have read the above codes and fees, and I understand the cost of my care at Windrose Chiropractic, 20423 Kuykendahl Rd., Ste. 400, Spring, TX 77379. I understand that I am responsible for payment of all deductible and co-payments related to my care. I understand that if my balance is not paid in a timely fashion as determined by the clinic, I promise to pay any and all collection, court, and attorney fees in the collection of my account. I further understand that if my treatment is associated with personal injury or accident claim, all medical bills will be paid at 100% of the above fee schedule regardless of the outcome of my case. I understand that if a check or debit is returned for insufficient funds, I will be charged a $25.00 service charge. I have read and fully understand the above financial terms and prices. Signed Date Witness Page 6 of 9
Patient Health Information Consent Form We want you to know how you Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we begin any health care operations we must require you to read and sign this consent form stating that you understand and agree with how your records will be used. 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. 1. The patient understands and agrees to allow this chiropractic office to use their Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operations, and coordination of care. As an example, the patient agrees to allow this chiropractic office to submit requested PHI to the Health Insurance Company (or companies) provided to us by the patient for the purpose of patient. Be assured that this office will limit the release of all PHI to the minimum needed for what the insurance companies require for payment. 2. The patient has the right to examine and obtain a copy of his or her own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI. Our office is not obligated to agree to those restrictions. 3. A patient s written consent to need only be obtained one time for all subsequent care given the patient in this office. 4. The patient may provide a written request to revoke consent at any time during care. This would not affect the use of those records for the care given prior to the written request to revoke consent but would apply to any given after the request has been presented. 5. For you security and right to privacy, all staff has been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures in our office. We have taken all precautions that are known by this office to assure that your records are not readily available to those who do not need them. 6. Patients have the right to file a formal complaint with our privacy official about any possible violations of these policies and procedures. 7. If the patient refuses to sign this consent for the purpose of treatment, payment and health care operations, the chiropractic physician has the right to refuse to give care. I have read and understand how my Patient Health Information will be used and I agree to these policies and procedures. Signature Name of Patient Date Page 7 of 9
Notice to Medicare Part B Beneficiaries Advance Notice of Non-covered Services 1. Medicare limits chiropractic reimbursement to manual manipulation. Reimbursement is based on medically necessary correction care only, maintenance care is not covered. 2. Medicare DOES NOT reimburse for charges of exams, x-rays, therapy, supplements or supports from a chiropractor. 3. X-rays and/or an exam may be required to update your condition should a new course of treatment be initiated. Medicare DOES NOT pay for either. 4. Medicare patients will be responsible for deductible amounts, non-covered charges and any denied visits which exceed Medicare guidelines. 5. Medicare secondary policies may be affected by Medicare denials. 6. Medicare supplemental policies only pay for what Medicare approves and does not pay (the manipulation is the only service Medicare approves for Chiropractic). X Our office agrees to Accept Assigment You will be responsible for a 20% co-payment on the allowable charge for manual manipulation in addition to those charges not covered which are listed above. Our office does not accept assignment You will be responsible for all charges incurred. Charges for manual manipulation will be assessed at Medicare s Limiting Charge. Our office will file your claims for you and reimbursement from Medicare will be based on 80% of the allowable charge for manipulation only. I have read and understand the limitations of my Medicare coverage and the affects it may have on any supplement or secondary policies. I am aware that I will be responsible for any charges that Medicare denies or deems over reasonable and necessary. Signature of Patient Date Page 8 of 9
Medicare Patients Medicare does NOT cover X-rays or any therapy with the exception of manual manipulation of the spine (adjustments) in a chiropractic office. None of the SUPPLEMENTAL plans will cover the cost of therapy or X-rays. They only cover the 20% of the manipulation charge that Medicare does not pay. Some secondary plans may cover a portion of the therapy and x- rays, but are often subject to a deductible. If you wish to receive therapy and x-rays in our office, even if it is NOT covered by Medicare or your Supplemental insurance, we can provide the service per your request. For a list of charges, please ask our front desk receptionist. Beginning in 2013, the out of pocket deductible for Medicare is $147.00. Sincerely, Windrose Chiropractic Page 9 of 9