MAJOR COMPLAINT INFORMATION
Using the symbols in the Pain Index, mark the areas on the diagram below where you are experiencing pain, followed by a number from 0 to 10 indicating the extent of the pain. (0 being no pain, 10 being the worst possible pain)
Check all that apply:
DAILY ACTIVITIES AFFECTED BY CONDITION
OTHER HEALTH HISTORY
REVIEW OF SYSTEMS
Check any of the following you now have or have had in the past:F = frequently O = occasionally N = never
PLEASE READ, SIGN, AND DATE BELOW
I hereby acknowledge that the information provided above is true and accurate. I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that Atlas Chiropractic Health Center 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 Atlas Chiropractic Health Center will be credited to my account on receipt. However, I clearlyunderstand and agree that all services rendered to me are my financial responsibility. Any dispute between legal parties shall be resolved by binding arbitration. It is not our intention to cause you undue hardship, however we must collect our receivables as efficiently as possible in order to continue our service to the community. Interest of 1% per month will be charged on delinquent accounts. If you discontinue your care, all charges are due immediately.
PLEASE READ: Please complete this questionnaire. It is designed to give us information as to how your NECK trouble has affected your ability to manage in everyday life.Please answer every section. Mark one box only in each section that most closely described you today.
PLEASE READ: Please complete this questionnaire. It is designed to give us information as to how your BACK (OR LEG) trouble has affected your ability to manage in everyday life.Please answer every section. Mark one box only in each section that most closely described you today.
Fill Out If You Have Been in a Job Related Injury
Thank you for choosing Atlas Chiropractic Health Center. We appreciate the opportunity to serve you and pledge to provide you with the very best medical care. The following contains information regarding our insurance benefits and financial responsibility policies. It is important that you read and understand this information prior to and during the duration of your treatment with us. Please initial each section.
Commercial Insurance Carriers:
1. As a courtesy, we will verify your benefit eligibility, however, since your insurance coverage is a contract between you and your insurance company, it is important that you understand the terms set forth by them regarding your benefits. It is your responsibility to contact your carrier prior to treatment if you have any questions or concerns regarding your coverage.
2. You are responsible for deductibles, co-payments, co-insurance payments or any other patient responsibility determined by your insurance carrier which is not otherwise covered. You are also responsible for knowing and tracking your total allowed visits per coverage term as well as if a prior authorization is required.
3. You are responsible for knowing the terms of your insurance policy, including, but not limited to physical and occupational therapy coverage. You will be responsible for any and all charges in full for the following scenarios:
a. Your health plan requires a prior authorization or referral from a physician before receiving treatment at Atlas Chiropractic Health Center and has not been provided by you
b. You receive services in excess of:
i. Your referral or authorization
ii. Your allowed visits per coverage term
c. Your health plan determines that the services you received at Atlas Chiropractic Health Center are not medically necessary and are therefore not covered by your plan
d. Your health plan coverage has expired, and you have not provided updated coverage information
4. You are required to provide us with all required information to bill your plan prior to your first appointment. If we are unable to verify your eligibility or benefits by the time of service, you will be considered a self-pay patient. Self-pay visits are expected to be paid in full at the time of service. Once verified information is provided, we will submit your claim and refund you once we have been paid by your carrier. You must notify us as soon as possible regarding any changes to your insurance coverage. Failing to do so could result in unpaid claims, and you will be responsible for the total balance of the unpaid claim. Atlas Chiropractic Health Center does not accept responsibility for incorrect information provided by you or your insurance carrier regarding your insurance benefits or other plan information. Any information we communicate to you has come directly from your carrier. Discrepancies should be addressed directly with them.
5. Billing statements are emailed monthly and can be expected to be received approximately 20-30 days after your insurance has processed a submitted claim. Please add firstname.lastname@example.org to your list of acceptable contacts. We are not responsible if our emails are sent to you spam or trash boxes. You must notify us of any errors or objections to your billing statement within 30 days of the statement date, otherwise the information will be considered accurate and any fees and expenses for services provided will be your responsibility.
6. Payment of your account balance is due within 30 days of the statement billing date. Payments can be made online, in person, or via mail. You can conveniently pay by visiting our website or making payment by PayPal, check, cash and all major debit and credit cards are also accepted. It is your responsibility to notify us of any address changes. Not receiving a bill due to inaccurate information on file is not an excuse for nonpayment.
7. All self-pay services and co-pays are required to be paid in full at the time of service. All self-pay patients without insurance in accordance with the law will be given a good faith estimate.
Work Injuries/Workers’ Compensation/L&I Claims
1. If treatment is part of a workers’ compensation/L&I claim it is your responsibility to ensure that your claim is opened and accepting claims for payment of services you will be receiving prior to your initial visit. It is also your responsibility to know how many visits you are allowed and to notify us if you are receiving subsequent care at another location that is also being billed under the same claim. This may affect how may visits will be paid to Atlas Chiropractic Health Center and we are not responsible for tracking visits that take place outside of our location. We will do our best to obtain additional authorized visits in a timely manner, however any unauthorized visits are ultimately your responsibility. It is important that you are regularly communicating with your claim manager so that you are aware of the coverage associated with your claim.
2. You are responsible for providing us all required information to bill your claim directly. This includes but is not limited to the following:
a. Claim Number
b. Carrier name and mailing address if the claim is being paid by a carrier other than the state of Washington.
c. Date of birth and date of injury
d. Primary Care Physician in charge of your case
e. Name and contact information for your claim manager
f. Commercial medical insurance plan information as back up billing source if needed
3. In the event that your claim is denied we will make an attempt to bill your primary commercial medical insurance plan. If the claim is denied by both parties, you will be billed and required to pay all amounts within 30 days of the statement billing date.
Auto Accidents/Third-Party Liability Injuries/PIP Claims
1. As a courtesy, we will bill your PIP carrier for services. It is your responsibility to ensure that your claim is open and accepting claims for payment of services you will be receiving prior to your initial visit. Legally we do not have access to information regarding the remaining available funds associated with your claim. It is your responsibility to know when your claim’s funds may become exhausted. It is common for us to only become aware that funds have been exhausted after several additional visits have occurred.
2. You are responsible for providing us all required information to bill your claim directly. This includes but is not limited to:
a. Name of your carrier
b. Claim number
c. Billing address
d. Name and contact information for your claim manager
e. Date of birth, date of injury and state where accident took place
f. Attorney Name and Contact Information (if applicable)
g. Commercial medical insurance plan information as back up billing source if needed
3. In the event that your funds become exhausted during your course of treatment, we will make an attempt to bill your primary commercial medical insurance plan. If the claim is denied by both parties, you will be billed and required to pay all amounts within 30 days of the statement billing date. We will only accept a delay in payment resulting from a settlement with a 3rd party dispute and/or litigation when a letter of protection from an attorney as a guarantee of payment has been signed by both patient and attorney and is on file.
Past Due Balances
Atlas Chiropractic Health Center will work with you to ensure a timely payment of your outstanding balance. In the event that it becomes necessary to begin collection proceedings to collect payment on a delinquent account, you understand that Atlas Chiropractic Health Center has the right to disclose to an outside collection agency all pertinent personal information required to collect payment for services rendered. You are responsible for all costs associated with any collection efforts. You also understand that information may be reported to a credit reporting agency which may have a negative effect on your credit history.
Please sign below acknowledging that you have read and understand the insurance benefits and financial policies stated above.