PATIENT INFORMATION Patient Name: Date of Birth: Sex: M F Age: Soc. Sec. #: - - Photo ID #: State: Address: City, State, Zip: Mobile Phone: Home Phone: Work Phone: Email address: We will not share your information. Occupation/Job: Employer: Single Married Children: # How did you hear about us? Referral: Google Yelp Insurance Other: I want to be notified of appointments or health information via text email phone May we email you newsletters or coupons? Yes No The Affordable Care Act (ObamaCare) requires that we ask the following information. You may refuse to answer these questions. Ethnicity: Hispanic Non-Hispanic Preferred Language (if other than English): Race: Native Alaskan/Native American Asian Black Pacific Islander White Smoking Status: never smoked former smoker daily smoker smoke occasionally heavy smoker Drug Allergies: none We will not share your personal information with anyone, except your insurance company and as required by the Affordable Care Act, without your permission. Please refer to our HIPAA documentation for details of our privacy policy. EMERGENCY CONTACT INFORMATION Whom may we contact in case of an emergency? Name: Relationship: Phone #: Address: City, State, Zip: Primary Physician: Phone #: Address: City, State, Zip: Signature: Date:
PATIENT MEDICAL HISTORY Patient Name: Have you ever experienced similar problems? No Yes Resolved. When? Have you been to a chiropractor before? No Yes Where? I have had X-rays MRI Other tests Did you bring a copy of the report? Yes No. Will you? Yes No. May we request them? Yes No Results of tests: List all other diagnoses you have: None. List medications you are taking: None. Are you currently receiving any other treatment? None List any allergies. None List any major accidents or illnesses. None List any surgeries. None List any hospitalizations. None List any family history of major illnesses (cancer, diabetes, stroke, heart disease, etc.) None Do you have any metal objects in your body (staples, shrapnel, IUD, pins, etc.)? No Yes List any recreational drugs (alcohol, coffee, tea, tobacco, marijuana, etc.) that you use Are you pregnant? No Yes How many weeks? Due Date: Ob/Gyn s Name: Phone: If any of this information changes, please notify us as soon as possible. Signature of Patient or Guardian Date
Pain Diagram Patient Name: Height: in. Weight: lbs. Please describe all your symptoms or pain on the pictures below, using the following symbols: A=Ache B=Burning T=Tingling N=Numbness S=Stabbing =Shooting O=Other Rate your pain on a scale of 0 to 10, where 0 = no pain and 10 = the worst pain imaginable. Either place a mark on the scale below, or write the pain level next to each symptom on the picture. For example, on the shoulder you could write A4 to indicate aching pain at level 4/10. 0-1 - 2-3 - 4-5 - 6-7 - 8-9 - 10 No Pain Much Pain Since starting treatment for this I feel much better slightly better same worse This is a new episode. What is the main problem today? When did this most recent episode start? The symptoms are present 0% -10 20 30 40 50 60 70 80 90 100% of the time. They prevent daily activities 0% -10 20 30 40 50 60 70 80 90 100% of the time. How did it start? What makes it worse? What makes it better? Are you able to work? Yes No With difficulty What treatment have you tried? Did it help? Have you had this problem before? No Yes Was it resolved? No Yes When? Signature of Patient or Guardian Date
MISSED APPOINTMENT, ASSIGNMENT OF BENEFITS, INFORMED CONSENT, AND PRIVACY POLICY Name of Patient: Missed Appointment Policy: We attempt to make reminder calls for appointments, but it is ultimately your responsibility to remember appointments. We require that any cancellations or rescheduling needs be made at least 24-hours in advance. We will charge $30.00 per visit for missed or cancelled appointments with less than 24-hours notice. Assignment of Benefits: As a courtesy, our office will file your insurance claim. Complete insurance information for primary and secondary insurance coverage must be provided, including referral forms from other providers and all identification and benefit cards/documents required for claim accuracy. Our office will call your insurance provider to verify coverage but this does not guarantee coverage for or payment of services. Co-payments are due at the time of service. Deductible and Co-insurance amounts applied to the claim will be due from the patient. Please read and sign below: I understand and agree that health and accident insurance policies are an agreement between my insurance carrier and me. Furthermore, I understand that Austin Kinesiology and Chiropractic will prepare the necessary forms to assist me in collecting from my insurance company. However, I clearly understand and agree that payment for all services rendered to me is my responsibility. It is also my understanding that any amount that the insurance does not cover is my responsibility. Payment is due in full, regardless of the outcome of any litigation or settlements pertaining to my claims. I also understand that if I terminate or suspend care and treatment, any fees outstanding for professional services will be immediately due and payable. I am responsible to know what, if any, insurance coverage/benefits I have. I hereby assign all health care benefits and insurance payments to which I am entitled to Austin Kinesiology and Chiropractic. 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. Patient Informed Consent: While the risks associated with chiropractic and physical therapy are small, they do exist and I will discuss those risks with my doctor. Associated risks include, but are not limited to: sprain/strain injuries, pain, discomfort, stroke, allergic reaction, and headache. If I have any medical conditions that increase the risk of treatment, I will inform the doctor. I also recognize that chiropractic and physical therapy may involve the touching of my body by a doctor or other members of the clinic's professional staff and that full or partial disrobing (gowns are provided) may be required to facilitate such care, all of which is expressly consented to by me. I acknowledge that I have had the opportunity to and will in the future ask my doctor about the potential risks involved with any aspect of my treatment. I will also be honest in giving the doctor feedback regarding each treatment and therapy session. Patient Privacy: As required by federal and state law, Austin Kinesiology and Chiropractic has made available, in writing, the clinic s policy regarding protection of private information and health care records. This written policy is publicly posted in the office and a copy is available to me for my records. I may request a copy of this at any time, and may revoke in writing certain permissions contained within this policy. Signature of Patient or Guardian Date
MEDICARE/MEDICAID COVERAGE FOR CHIROPRATIC CARE WHAT SERVICES ARE COVERED BENEFITS OF YOUR INSURANCE PLAN Your Medicare/Medicaid, M/M, coverage of chiropractic care is limited. It does not pay for all services, even some care that you and Dr. Bryson have good reason to think you need. M/M will only pay for your chiropractic adjustment (manipulative treatment) when it meets M/M specific rules. There are three categories of M/M services: 1) Always-Covered 2) Perhaps-Covered & 3) Non-Covered. ALWAYS-COVERED SERVICES A covered service is for when you are injured or when you are in pain due to a bad spinal condition. MEDICARE pays for your rehabilitation as long as you are improving. MEDICAID pays up to 12 visits per service year for your rehabilitation of a spinal condition(s). This phase of care is called active treatment. It will be shown on your claim forms and payment reports with your service code. For example, 98940-AT. PERHAPS-COVERED SERVICES Your chiropractic adjustment must be clinically needed to correct a problem of the spine, according to M/M rules. If M/M determines that your condition is not Medically Necessary they will not pay. When we know or believe that your chiropractic adjustment is no longer covered, we will discuss this matter with you to determine what course of continuing care you would prefer. NON-COVERED SERVICES According to current laws, most of the services in our office are NON-COVERED. Hopefully legislators will change that someday and treat Doctors of Chiropractic like all other doctors. Until then, here is a summary: EXAMPLES OF NON-COVERED SERVICES All Services Other Than Chiropractic Adjustments: Various Chiropractic Adjustments or Treatments: Office Visits to evaluate and manage, re-evaluate, Non-Spinal Manipulation for joints other than the advise, or give counsel regarding your health. spine like the shoulder, elbow, hip, etc. Physiotherapy such as massage, traction, electrical Maintenance Care you are stable and not making any stimulation, neuromuscular re-education, etc. more improvement. Other X-rays, Laboratory, Supplies, Vitamins, etc. Wellness Care to promote better health. REQUIRED FINANCIAL RESPONSIBILITY ACKNOWLEDGEMENTS: FOR MEDICARE CLIENTS ONLY: MEDICARE Advance Beneficiary Notice of Noncoverage (ABN) (Please see reverse side for acknowledgement form) OVER FOR MEDICAID CLIENTS ONLY: MEDICAID Client Acknowledgment Statement: (Please only sign below if you are a Medicaid recipient) I understand that, in the opinion of, the services or items that I have requested to be provided to me may not be covered under the Texas Medical Assistance Program as being reasonable and medically necessary for my care. I understand that the HHSC or its health insuring agent determines the medical necessity of the services or items that I request and receive. I also understand that I am responsible for payment of the services or items I request and receive if these services or items are determined not to be reasonable and medically necessary for my care. X Signature of patient or parent/guardian Patient s name Date
A. 12701 Research Blvd., Ste. 309, Austin, TX 78759 (512) 250-9799 B. Patient Name: C. Identification Number: Advance Beneficiary Notice of Noncoverage (ABN) NOTE: If Medicare doesn t pay for the services below D., you may have to pay. Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the services below. D. Services Likely Not Covered E. Reason Medicare May Not Pay: F. Estimated Cost Evaluation & Management Services (Exam/Office Visit), Electrical Stimulation, Ultrasound Therapy, Massage, Traction, Spinal Decompression, Extraspinal Manipulation These are NON-COVERED services under Medicare when ordered and/or delivered by a chiropractic physician. $25-$75 Maintenance Care Medicare never pays for maintenance care $25-$75 WHAT YOU NEED TO DO NOW: Read this notice, so you can make an informed decision about your care. Ask us any questions that you may have after you finish reading. Choose an option below about whether to receive the services listed above. Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this. G. OPTIONS: Check only one box. We cannot choose a box for you. OPTION 1. I want the services listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles. OPTION 2. I want the services listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed. OPTION 3. I don t want the services listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay. H. Additional Information: This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048). Signing below means that you have received and understand this notice. You also receive a copy. I. Signature: J. Date: CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call: 1-800-MEDICARE or email: AltFormatRequest@cms.hhs.gov. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850. Form CMS-R-131 (Exp. 03/2020) Form Approved OMB No. 0938-0566