: General Information First name: Middle initial: Last name: of Birth: Street address: City State Zip Marital Status: Single Married Other Email Address: Cell Phone: Cell phone provider: Home Phone: Center for Medicare & Medicaid services requires Island Family Chiropractic Wellness to report both race and ethnicity (circle one) Race: American Indian or Alaska Native / Asian / Black or African American / White (Caucasian) Native Hawaii or Pacific Islander / Other / I decline to answer Ethnicity: Hispanic or Latino / Not Hispanic or Latino / I decline to answer How did you hear about us? Friend Internet Advertisement/Flyer Other, please explain Who can we thank for your referral: Page 1 of 5
Do you have any medication allergies? Medication Name Reaction Onset Comments Have you ever had an auto accident? Past year Past 5 years Over 5 years ago Any other personal injuries or accidents, please describe Employment Information Employer Name Occupation Employer Address Phone # City State Zip Emergency Contact Please provide the information about the nearest relative or friend. First name Last name Best number to contact them Home Work Mobile Relation to patient I chose to decline receipt of my clinical summary after every visit (these summaries are often blank as a result of the nature and frequency of chiropractic care) Signature of patient or person acting on patients behalf Page 2 of 5
INSURANCE INFORMATION *Please provide your insurance card and ID to the front desk to copy* Is your condition due to an auto accident or job related injury? Yes / No Are you covered by Medicare? Yes / No Health Insurance Name: Phone Number: Insured s First name Last Name of Birth Relationship to Insured Insurance/Member ID # Group ID # * I understand and agree that the health and accident insurance policies are an arrangement between the insurance carrier and me. This office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to me and that I am personally responsible for payment. I also understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered to me will be immediately due and payable. Signature: : ***Below will be filled out by Island Family Chiropractic Wellness*** : Spoke to: Ref # Effective : Plan Type: HSA/HRA: Y or N Deductible: Met: Calendar Year/Plan Year (Circle one) Co Pay/Co Insurance: Insurance Pays: Visit Limits: Visits Used: Max Out of Pocket: Applied Amount to Max: Page 3 of 5
ACKNOWLEDGMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES I have received a copy of Island Family Chiropractic Wellness Notice of Privacy Practices. I understand that I have certain rights to privacy regarding my protected health information. I understand that his information can and will be used to: Conduct, plan and direct my treatment and follow-up among the health care providers who may be directly and indirectly involved in providing my treatment. Obtain payment from third-party payers. Conduct normal health care operations such as quality assessments and accreditation. Print Name Signature For Office Use Only: We attempted to obtain written Acknowledgment of receipt of our Notice of Privacy Practices, but Acknowledgment could not be obtained because: Individual refused to sign Communication barriers prohibited obtaining the Acknowledgment An emergency situation prevented us from obtaining Acknowledgment Other (Please Specify) Staff Signature Page 4 of 5
Insurance Coverage Financial Policy Welcome to Island Family Chiropractic Wellness. Your insurance policy is an agreement between you and your insurer, not between your insurer and this clinic. Like all types of care, coverage for chiropractic services varies from insurer to insurer and plan to plan. Most insurance policies require the beneficiary to pay co-insurance, copayment and/or a deductible. For example: if you have a deductible of $100, and your insurance pays 80%, you are responsible for 20% of all charges incurred during the year after you have paid your $100 at the beginning of the year. Our clinic will call your insurer to verify your benefits, however, we are not responsible for your insurer s final payment and benefit determinations. Payments In order to help you determine your responsibility toward payment for services, please read the following, and initial your preference for the method of payment of your account. Please notify this office if the status of your insurance changes. Private Pay: (please initial) A As I have no insurance, I agree to assume all responsibility and to keep my account current by paying for services when they are rendered. B I have insurance, but I wish to file my claims personally, and I agree to assume all responsibility and to keep my account current by paying for each visit at the time services are rendered. Health Insurance: (please initial) C I would like this clinic to bill my insurance. I understand I am responsible for the costs of treatment. Missed Appointments It is the policy of Island Family chiropractic Wellness to assess a $10 missed visit fee to patients who cancel appointments with less than a 24-hour notice. One missed visit will not result in the assessment of a fee, but you will be charged for any additional missed visits. This clinic provides care for many individuals and missed visits result in time lost that could have been used to provide care for others. My initials here indicate that I understand the above missed visit policy. I understand that all health services rendered to me and charged to me are my personal financial responsibility. I understand and agree to the conditions of this policy. Signature Page 5 of 5