Today s date: (Please Print Clearly) Primary Care Physician and clinic: PATIENT INFORMATION Last name: First: MI: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid Is this your legal name? Yes No If not, what is your legal name? (Former name): Birth date: / / Age: Sex: M F Street address: Social Security no.: Primary phone no.: ( ) P.O. box: City: State: ZIP Code: Occupation: Employer: Employer City: Chose clinic because/referred to clinic by (please check one Dr. Insurance Plan Walk-In box): Family Friend Close by home/work Newspaper ad Other: Who were you referred by? INSURANCE INFORMATION *PLEASE GIVE YOUR INSURANCE CARD TO THE RECEPTIONIST* Please indicate primary Premera Regence Aetna First Choice Cigna insurance Lifewise Medicare Group Health Options Other: ID no.: Group no.: Claims address (found on back of card): Phone no.: Patient s relationship to subscriber: Self Name of secondary insurance (if applicable): Spouse Child Other: Subscriber s name: ID no.: Group no.: Claims address (found on back of card): Phone no: Patient s relationship to subscriber: Self Spouse Child Other IN CASE OF EMERGENCY Name: Relationship to patient: Home phone no.: Work phone no.: ( ) ( ) The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Pain Relief Partners or insurance company to release any information required to process my claims. X Patient/Guardian signature Date
Patient Name: History of Illness / Injury / Pain Date of Birth: CHIEF COMPLAINT & LOCATION Chief Complaint and its location: When did the pain start? What caused the pain? Please put an X on ALL spots you are experiencing pain How often do you experience this pain? Constant Frequent Intermittent Occasional SEVERITY On a scale of 0 to 10 with 0 representing no pain and 10 being the most severe pain imaginable, use the key below to rate the severity of your pain. 0 = None 1 = Minimal 2 = Very Mild 3 = Moderate 4 = Mild to Moderate 5 = Moderate 6 = Moderate to Severe 7 = Mildly Severe, Restricts some activity 8 = Severe, limits most activity 9 = Very Severe 10 = Excruciating Sitting here today, right now, what is the intensity of your pain on a scale of 0 to 10? What is the least intense pain the symptom has been on a scale of 0 to 10? What is the most intense the symptom has been on a scale of 0 to 10? ASSOCIATED SIGNS & SYMPTOMS How does this symptom affect your movement? Inflexibility Spasms Other: Stiffness Cramps QUALITY How would you best describe the sensation of the pain/symptom? Deadness Stabbing Burning Sharp Prickly Hurting Shooting Aching Numb Pulsating Throbbing Excruciating Crawling Pins & Needles Stinging Tingling Pounding Dull Patient Signature: Todays Date:
Patient Name: Date of Birth: Does this pain radiate or travel? YES / NO If YES, where to? MODIFYING FACTORS What aggravates the pain/symptom? Sitting Exercising Getting in/out of OTHER: Standing Repetitive car Sneezing movement Driving Lifting Looking up & Getting out of Pushing down bed Walking Looking side/side Pulling Climbing Stairs Coughing Carrying What relieves the pain/symptom? Over the past weeks/months this complaint is: Improving Getting worse About the same Have you seen anyone for this condition? YES / NO If YES, Whom?: Have you ever had any of the following? Medical Problem(s) YES NO If Yes, Explain Allergies (Food, Medication, Etc.) Angina / Chest Pain Arthritis Asthma Broken Bones Cancer Diabetes Gout Heart Disease HIV Permanent Disabilities Stroke Thyroid Problems Other MAJOR Past Medical History to Note: Patient Signature: Todays Date:
Patient Name: Date of Birth: What Medications are you currently taking? Have you had any of the following surgeries? SURGERY Yes No Year SURGERY Yes No Year SURGERY Appendix MEN OTHER Colon Gall Bladder Heart Hernia Kidney Stomach Tonsils Prostate Breast Ovaries Uterus WOMEN Any other MAJOR injuries, surgeries, or hospitalizations to note? Do you have a pace maker? YES / NO Are you pregnant? YES / NO Do you think you might be pregnant? YES / NO Who is your primary care physician? Marital Status (Circle one): Single / Married / Divorced / Separated / Widowed Spouse s Name: Spouses Birthdate: Do you have any children? YES / NO If YES, how many? How often do you exercise? Never Rarely Occasionally Moderately Regularly Intensity of Exercise: Low Level Medium Level High Level Competition Level Sufficient Rest: Never Average Hours of Sleep per Night: Rarely Occasionally Moderately 1 3 3-6 6-8 8+ Well Balanced Diet: Never Rarely Patient Signature: Occasionally Moderately Todays Date:
Patient Name: Date of Birth: Are you a current smoker? (Circle One) - YES / NO YES, how many packs per week?: 0 to 1 Are you a former Smoker? (Circle One) YES / NO If 1 to 2 3+ Describe your Alcohol consumption: Daily Weekly Monthly Occasionally Rarely Never Have you ever used illicit drugs? YES / NO Hobbies: Are you experiencing any other pain in a different area? YES / NO If YES, explain what areas & type of pain: ---------------------------------------------------------------------- OFFICE USE ONLY ---------------------------------------------------------------------- Notes: Patient Signature: Todays Date:
ASSIGNMENT OF BENEFITS / ERISA AUTHORIZED REPRESENTATIVE FORM Assignment of Insurance Benefits Appointment as Legal Authorized Representative I hereby assign all applicable health insurance benefits and all rights and obligations that I and my dependents have under my health plan to the Provider and The Force Law Firm PC and their affiliated law firms (hereinafter, My Authorized Representatives ) and I appoint them as my authorized representative with the power to: File medical claims with the health plan File appeals and grievances with the health plan Institute any necessary litigation and/or complaints against my health plan naming me as plaintiff in such lawsuits and actions if necessary (or me as guardian of the patient if the patient is a minor) Discuss or divulge any of my personal health information or that of my dependents with any third party including the health plan I certify that the health insurance information that I provided to Provider is accurate as of the date set forth below and that I am responsible for keeping it updated. I am fully aware that having health insurance does not absolve me of my responsibility to ensure that my bills for professional services from Provider are paid in full. I also understand that I am responsible for all amounts not covered by my health insurance, including co-payments, co-insurance, and deductibles. Authorization to Release Information I hereby authorize My Authorized Representatives to: (1) release any information necessary to my health benefit plan (or its administrator) regarding my illness and treatments; (2) process insurance claims generated in the course of examination or treatment; and (3) allow a photocopy of my signature to be used to process insurance claims. This order will remain in effect until revoked by me in writing. ERISA Authorization I hereby designate, authorize, and convey to My Authorized Representatives to the full extent permissible under law and under any applicable insurance policy and/or employee health care benefit plan: (1) the right and ability to act as my Authorized Representative in connection with any claim, right, or cause of action including litigation against my health plan (even to name me as a plaintiff in such action) that I may have under such insurance policy and/or benefit plan; and (2) the right and ability to act as my Authorized Representative to pursue such claim, right, or cause of action in connection with said insurance policy and/or benefit plan (including but not limited to, the right and ability to act as my Authorized Representative with respect to a benefit plan governed by the provisions of ERISA as provided in 29 C.F.R. 2560.5031(b)(4) with respect to any healthcare expense incurred as a result of the services I received from Provider and, to the extent permissible under the law, to claim on my behalf, such benefits, claims, or reimbursement, and any other applicable remedy, including fines. I authorize communication with the Provider and his authorized representatives by email and my email address is @. I understand I can revoke this authorization in writing at any time A photocopy of this Assignment/Authorization shall be as effective and valid as the original. Patient Signature Date
HIPAA DECLARATION The practice: (a) Is required by federal law to maintain the privacy of your Protected Health Information and to provide you with this Privacy Notice detailing the Practice s legal duties and privacy with respect to your Protected Health Information. (b) Under the Privacy Rule, may be required by State law to grant greater access or maintain greater restrictions on the use or release of your Protected Health Information than that which is provided for under federal law. (c) Is required to abide by the terms of the 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 Protected Health Information that is maintains. (e) Will distribute any revised Privacy Notice to you prior to implementation. (f) Will not retaliate against you for filing a complaint. This notice is effective as of 07/26/2004. EFFECTIVE DATE PATIENT ACKNOWLEDGEMENT By subscribing my name below, I acknowledge receipt of this notice, and my understanding and my agreement to its terms. PATIENT DATE FOR PRACTICE USE ONLY Practice Documentation of Good Faith Effort to Obtain Acknowledgement. Patient s acknowledgement of this notice could not be obtained because: Patient refused to sign Communication barrier prohibited obtaining acknowledgement Emergency circumstances Other Details: Signature of Practice Date
INFORMED CONSENT FOR CHIROPRACTIC TREATMENT I hereby request and consent to the performance of chiropractic treatments (also known as chiropractic adjustments or chiropractic manipulative treatments) and any other associated procedures: physical examination, tests, diagnostic x-rays, physio therapy, physical medicine, physical therapy procedures, etc. on me by the doctor of chiropractic named above and/or other assistants and/or licensed practitioners. I understand, as with any health care procedures, that there are certain complications, which may arise during chiropractic treatments. Those complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, Horner's Syndrome, diaphragmatic paralysis, cervical myelopathy and costovertebral strains and separations. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to complications including stroke. I do not expect the doctor to be able to anticipate all risks and complications, and I wish to rely upon the doctor to exercise judgment during the course of the procedure(s) which the doctor feels at the time, based upon the facts then known, that are in my best interest. I have had an opportunity to discuss the nature, purpose and risks of chiropractic treatments and other recommended procedures. I have had my questions answered to my satisfaction. I also understand that specific results are not guaranteed. If there is any dispute about my care, I agree to a resolution by binding arbitration according to the American Arbitration Association guidelines. I understand soreness, soft tissue injury, rib injury, stroke, and other problems can occur. While these are very rare please report them to your doctor. I have read (or have had read to me) the above explanation of the chiropractic treatments. I state that I have been informed and weighed the risks involved in chiropractic treatment at this health care office. I have decided that it is in my best interest to receive chiropractic treatment. I hereby give my consent to that treatment. I intend for this consent to cover the entire course of treatment for my present condition(s) and for any future conditions(s) for which I seek treatment. Sign only after you understand and agree to the above. Printed name of Patient x Signature of Patient x Signature of Representative (parent or guardian) Date Date