Statera Online Form _ Application for Care Adult

APPLICATION FOR CARE-HISTORY
Whom may we thank for referring you to our office?

Patient Demographics
Full Name *

First Name Last Name
Birth Date *

Month Day Year
Age *
Gender

Male Female
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Home Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
Mobile Phone *

Area Code Phone Number
Do you have Insurance *

Yes No
Marital Status *

Single Married
Social Security Numb
Employer *
Occupation *
Spouse's Name
Spouse's Employer
Number of Children and Ages
Emergency Contact Name *
Emergency Contact Number *

Area Code Phone Number
Relationship *

History of Complaint

Please identify the condition(s) that brought you to this office:
Primary *
Secondary
Third
Fourth

Past History

If you have ever been diagnosed with any of the following conditions, please indicate status.
Broken Bone
Dislocations
Tumor
Rheumatoid Arthritis
Fracture
Disability
Cancer
Heart Attack
Osteo Arthritis
Diabetes
Cerebral Vascular
Other Serious Condition

PLEASE identify ALL PAST and any CURRENT conditions you feel may be contributing to your present problem:

	How long ago	Type of Care Received	By Whom
Injuries
Surgeries
Childhood Diseases
Adult Diseases

Statera Chiropractic

Informed Consent
REGARDING:

Chiropractic Adjustments, Modalities, and Therapeutic Procedures
I have been advised that chiropractic care, like all forms of health care, holds certain risks. While the risk are most often very minimal, in rare cases, complications such as sprain/strain injuries, irritation of a disc condition, and although rare, minor fractures, and possible stroke, which occurs at a rate between one instance per one million to one per two million, have been associated with chiropractic adjustments.

Treatment objectives as well as the risks associated with chiropractic adjustments and, all other procedures provided at Statera Chiropractic have been explained to me to my satisfaction and I have conveyed my understanding of both to the doctor. After careful consideration, I do hereby consent to treatment by any means, method, and or techniques, the doctor deems necessary to treat my condition at any time throughout the entire clinical course of my care.
Patient or Authorized Person’s Signature *

Clear
If unable to sign, please Type your Name here to Electronically Accept Signature *
Today’s Date *

Month Day Year
REGARDING:

X-rays/Imaging Studies
FEMALES ONLY → please read carefully and check the boxes, include the appropriate date, then sign below if you understand and have no further questions, otherwise see our receptionist for further explanation.
The last date of my mentstrual cycle was on:
Date

Month Day Year
Answer

I have been provided a full explanation of when I am most likely to become pregnant, and to the best of my knowledge, I am not pregnant.
By my signature below I am acknowledging that the doctor and or a member of the staff has discussed with me the hazardous effects of ionization to an unborn child, and I have conveyed my understanding of the risks associated with exposure to x-rays. After careful consideration I therefore, do hereby consent to have the diagnostic x-ray examination the doctor has deemed necessary in my case.
Patient or Authorized Person’s Signature

Clear
If unable to sign, please Type your Name here to Electronically Accept Signature
Today’s Date

Month Day Year

STATERA CHIROPRACTIC NOTICE OF PRIVACY PRACTICE
This office is required to notify you in writing, that by law, we must maintain the privacy and confidentiality of your Personal Health Information. In addition we must provide you with written notice concerning your rights to gain access to your health information, and the potential circumstances under which, by law, or as dictated by our office policy, we are permitted to disclose information about you to a third party without your authorization. Below is a brief summary of these circumstances. If you would like a more detailed explanation, one will be provided to you. In addition, you will find we have placed several copies in report folders labeled ‘HIPAA’ on tables in the reception. Once you have read this notice, please sign the last page, and return only the signature page (page 2) to our front desk receptionist. Keep this page for your records.

PERMITTED DISCLOSURES:
1. Treatment purposes - discussion with other health care providers involved in your care.
2. Inadvertent disclosures - open treating area mean open discussion. If you need to speak privately to the doctor, please let our staff know so we can place you in a private consultation room.
3. For payment purposes - to obtain payment from your insurance company or any other collateral source.
4. For workers compensation purposes - to process a claim or aid in investigation.
5. Emergency - in the event of a medical emergency we may notify a family member.
6. For Public health and safety - in order to prevent or lessen a serious or imminent threat to the health or safety of a person or general public.
7. To Government agencies or Law enforcement - to identify or locate a suspect, fugitive, material witness or missing person.
8. For military, national security, prisoner and government benefits purposes.
9. Deceased persons - discussion with coroners and medical examiners in the event of a patient’s death.
10. Telephone calls or emails and appointment reminders - we may call your home and leave messages regarding a missed appointment or apprize you of changes in practice hours or upcoming events.
11. Change of ownership- in the event this practice is sold, the new owners would have access to your PHI.
YOUR RIGHTS:
1. To receive an accounting of disclosures.
2. To receive a paper copy of the comprehensive “Detail” Privacy Notice.
3. To request mailings to an address different than residence.
4. To request Restrictions on certain uses and disclosures and with whom we release information to, although we are not required to comply. If, however, we agree, the restriction will be in place until written notice of your intent to remove the restriction.
5. To inspect your records and receive one copy of your records at no charge, with notice in advance.
6. To request amendments to information. However, like restrictions, we are not required to agree to them.
7. To obtain one copy of your records at no charge, when timely notice is provided (72 hours). X-rays are original records and you are therefore not entitled to them. If you would like us to outsource them to an imaging center, to have copies made, we will be happy to accommodate you. However, you will be responsible for this cost.
COMPLAINTS:
If you wish to make a formal complaint about how we handle your health information, please call Dr. Doug Gregory at (385) 288-0934. If he is unavailable, you may make an appointment with our office director to see her within 72 hours or 3 working days. If you are still not satisfied with the manner in which this office handles your complaint, you can submit a formal complaint to:

DHHS, Office of Civil Rights
200 Independence Ave. SW
Room 509F HHH Building
Washington DC 20201

I have received a copy of STATERA CHIROPRACTIC’S Patient Privacy Notice. I understand my rights as well as the practice’s duty to protect my health information, and have conveyed my understanding of these rights and duties to the doctor. I further understand that this office reserves the right to amend this “Notice of Privacy Practice” at a time in the future and will make the new provisions effective for all information that it maintains past and present.

I am aware that a more comprehensive version of this “Notice” is available to me and several copies kept in the reception area. At this time, I do not have any questions regarding my rights or any of the information I have received.
Patient's Name *

First Name Last Name
Birthday *

Month Day Year
Patient’s Signature *

Clear
If unable to sign, please Type your Name here to Electronically Accept Signature
Date *

Month Day Year
Should be Empty:

APPLICATION FOR CARE-HISTORY

Patient Demographics

History of Complaint

Past History

Social History

Family History

Review of Systems

QUADRUPLE VISUAL ANALOGUE SCALE

REGARDING:

REGARDING:

STATERA CHIROPRACTIC NOTICE OF PRIVACY PRACTICE