Chiropractic Services Provided• Consultation-includes practice member history. This service is complimentary.• Examination (new patient or established patient)-includes one or more of the following: thermography, surface electromyography, range of motion, motion and/or static palpation, leg check.• Chiropractic Adjustment – The actual re-alignment of the vertebra. A specific instrument is used to make the spinal adjustment. 1 to 3 specific adjustments will be made per visit, re-aligning the vertebra.• X-rays – Specific x-ray views taken of your spine to determine a misalignment/subluxations of your vertebrae. These can also be used to indicate progress after period of care.**All charges will be reviewed and authorized by practice member before any charges are rendered
Release of Authorization/Assignment of BenefitsI authorize the release of any information necessary to process my insurance claims. I authorize and request payment of insurance benefits directly to the doctors. I agree that this authorization will cover all services rendered until I revoke the authorization. I agree that a photocopy of this form may be used in place of the original. All professional services rendered are charged to the patient. It is customary to pay for services when rendered unless other arrangements have been made in advance. I understand that I am financially responsible for charges not covered by this assignment.
WRITTEN CONSENT FOR A CHILD/MINORIF THIS HEALTH PROFILE IS FOR A MINOR/CHILD, PLEASE FILL OUT AND SIGN BELOW
I AUTHORIZE DRS. MATTHEW AND/OR TAYLOR FILTZ AND ALL FOUNDATION CHIROPRACTIC INC. STAFF TO PERFORM DIAGNOSTIC PROCEDURES, RADIOGRAPHIC EVALUATIONS, RENDER CHIROPRACTIC CARE AND PERFORM CHIROPRACTIC ADJUSTMENTS TO MY MINOR/CHILD.AS OF THIS DATE, I HAVE LEGAL RIGHT TO SELECT AND AUTHORIZE HEALTH CARE SERVICES FOR MY MINOR/CHILD. IF MY AUTHORITY TO SELECT AND AUTHORIZE CARE IS REVOKED OR ALTERED, I WILL IMMEDIATELY NOTIFY FOUNDATION CHIROPRACTIC.
Witness Signature (Office Staff) _______________________________________
TERMS OF ACCEPTANCEWhen a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective.Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment.ADJUSTMENT: An adjustment is the specific application of forces to facilitate the body’s correction of vertebral subluxations. Our chiropractic method of correction is by specific adjustments to the spine.HEALTH: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity.VERTEBRAL SUBLUXATION: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body’s innate ability to express its maximum health potential.We do not offer to diagnose or treat any disease or condition other than vertebral subluxations. However, if during the course of chiropractic spinal examination, we encounter non-chiropractic or unusual finding, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of another health care provider.Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body’s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations.
I, First Name* Last Name* have read and fully understand the above statements.All questions regarding the doctor's objectives pertaining to my care in this office have been answered to my complete satisfaction.I therefore accept chiropractic care on this basis.
Notice of Privacy Practices AcknowledgementI understand that I have certain rights of privacy regarding my protected health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to:1. Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.2. Obtain payment from third-party payers.3. Conduct normal healthcare operations, such as quality assessments and physician’s certifications.I acknowledge that I may request your NOTICE OF PRIVACY PRACTICES containing a more complete description of the uses and disclosures of my health information. I also understand that I may request, in writing, that you restrict how my private information is used to disclosed to carry out treatment, payment, or healthcare operation. I also understand you are not required to agree to my requested restrictions, but if you do agree, then you are bound to abide by such restrictions.
X-RAY AUTHORIZATIONAS YOUR HEALTHCARE PROVIDER, WE ARE LEGALLY RESPONSIBLE FOR YOURCHIROPRACTIC RECORDS. WE MUST MAINTAIN A RECORD OF YOUR X-RAYS IN OUR FILES. AT YOUR REQUEST, WE WILL PROVIDE YOU WITH A COPY OF THE X-RAYS IN OUR FILES.PLEASE NOTE: X-RAYS ARE UTILIZED IN THIS OFFICE TO HELP LOCATE AND ANALYZE VERTEBRAL SUBLUXATIONS. THESE X-RAYS ARE NOT USED TO INVESTIGATE FOR MEDICAL PATHOLOGY. THE DOCTORS OF FOUNDATION CHIROPRACTIC INC. DO NOT DIAGNOSE OR TREAT MEDICAL CONDITIONS; HOWEVER, IF ANY ABNORMALITIES ARE FOUND, WE WILL BRING IT TO YOUR ATTENTION SO THAT YOU CAN SEEK PROPER MEDICAL ADVICE.BY SIGNING BELOW, YOU ARE AGREEING TO THE ABOVE TERMS AND CONDITIONS
FEMALE PATIENTS ONLY: TO THE BEST OF MY KNOWLEDGE, I BELIEVE I AM NOTPREGNANT AT THE TIME X-RAYS ARE TAKEN AT FOUNDATIONCHIROPRACTIC INC
Please select the number that best describes the question asked. If you have more than one complaint, please answer each question for each individuation complaint and indicate the score of each complaint.
EXAMPLE: 0 = No Pain | 10 = Worst Possible Pain
Score: Q1 _____+Q2_____+Q3_____=_____/3x10=_____
(Low Intensity = 50)