New Patient Intake Forms

Green Chiropractic Intake Forms
Patient Information
Name*

First NameMiddle InitialLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Contact*
Occupation
Marital Status
How were you referred to our office?
Emergency Contact Person*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship*
Primary Care Doctor's Name

First NameLast Name
Phone Number

Area CodePhone Number

Are you currently taking any medications or supplements? If yes, please list them below:
If you have had a stroke, please list the date below:
Date
Family History:(select all that apply)*

CancerDiabetesHigh Blood PressureHeart Problems/StrokeRheumatoid ArthritisN/A
Have you had any major illnesses, injuries, falls, or auto accidents? (include dates):
Are there any unrelated health conditions?
Did you undergo any surgery in the past? If yes, please indicate the name or location of the surgery:
Are you wearing any implantable medical devices? If yes, what are these devices?
Women: Are you pregnant?
If yes, how many weeks?
I certify to the best of my knowledge, the above information is complete and accurate. If the health plan information is not accurate, or if I am not eligible to receive a health care benefit through this provider, I understand that I am liable for all charges for services rendered and I agree to notify this doctor immediately whenever I have changes in my health condition or health plan coverage in the future. I understand that my chiropractor may need to contact my physician if my condition needs to be co-managed. Therefore I give authorization to my chiropractor to contact my physician, if necessary.
Signature of Patient (or Guardian if minor)*

Clear
Patient/Guardian?*
Date*

MonthDayYear
Date

Patient Health Information Consent Form

HIPAA
Name*

First NameMiddle InitialLast Name
We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we will begin any health care operations we must require you to read and sign this consent form stating that you understand and agree with how your records will be used. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent.

1.The patient understands and agrees to allow this chiropractic office to use their Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operations, and coordination of care. As an example, the patient agrees to allow this chiropractic office to submit requested PHI to the Health Insurance Company (or companies) provided to us by the patient for the purpose of payment. Be assured that this office will limit the release of all PHI to the minimum needed for what the insurance companies require for payment.

2. The patient has the right to examine and obtain a copy of his or her own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI. Our office is obligated to agree to those restrictions only to the extent they coincide with state and federal law.

3.A patient's written consent need only be obtained one time for all subsequent care given the patient in this office.

4. The patient may provide a written request to revoke consent at any time during care. This would not effect the use of those records for the care given prior to the written request to revoke consent but would apply to any care given after the request has been presented.

5. Our office may contact you periodically regarding appointments, treatments, services, or charitable work performed by our office. You may choose to opt-out of any communications at any time.

6.For your security and right to privacy, all staff has been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures in our office. We have taken all precautions that are known by this office to assure that your records are not readily available to those who do not need them.

7.Patients have the right to file a formal complaint with our privacy official and the Secretary of HHS about any possible violations of these policies and procedures without retaliation by this office.

8. Our office reserves the right to make changes to this notice and to make the new notice provisions effective for all protected health information that it maintains. You will be provided with a new notice at your next visit following any change.

9. This notice is effective on the date stated below.

10. If the patient refuses to sign this consent for the purpose of treatment, payment and health care operations, the chiropractic physician has the right to refuse to give care.

I have read and understand how my Patient Health Information will be used and I agree to these policies and procedures.
Signature of Patient (or Guardian if minor)*

Clear
Patient/Guardian?*
Date*

MonthDayYear
Date

Informed Consent

Green Chiropractic, Dr. Jeremy Green, DC
Name*

First NameMiddle InitialLast Name
The doctor will use his hands or a mechanical instrument upon your body in such a way as to move your joints. This procedure is referred to as "Spinal Manipulation" or "Spinal Adjustment" As the joints in your spine are moved, you may experience a "pop" as part of the process

There are certain complications that can occur as a result of a spinal manipulation. These complications include, but are not limited to: muscle strain, cervical myelopathy, disc and vertebral injury, fractures, strains and dislocations, Bernard-Horner's Syndrome (also known as oculosympathethetic palsy), costovertebral strains and separation. Rare complications include, but are not limited to stroke. The most common complication or complaint following spinal manipulation is an ache or stiffness at the site of adjustment.

The doctor is aware of these complications, and in order to minimize their occurrence, he will take precautions. These precautions include, but are not limited to taking a detailed clinical history of you and examining you for any defect which would cause a complication. This examination may include the use of x-rays. The use of x-ray equipment may pose a risk if you are pregnant. If you are pregnant, please inform the doctor during your exam.
Signature of Patient (or Guardian if minor)*

Clear
Patient/Guardian?*
Date*

MonthDayYear
Date

Financial Policy
Name*

First NameMiddle InitialLast Name
The doctor's recommendations are based on a desire to see you get well and stay well. Chiropractic care is covered under many insurance plans. Most of our patients that have health or accident insurance will fall under one of the plans discussed in this policy. Regardless of your coverage, the doctor will suggest the chiropractic care he thinks you need. We ask that you read and understand our policy as it applies to your particular situation.

PATIENTS WITHOUT INSURANCE
We request that 100% of each visit be paid at the time of the visit. We are happy to accept cash, personal checks, Discover, MasterCard or Visa.

GROUP OR INDIVIDUAL INSURANCE
Your insurance is an agreement between you and your insurance company, not between your insurance company and our office. We cannot be certain if your insurance covers chiropractic, although most policies do provide coverage. The amount they pay varies from one policy to another. When possible, we will verify benefits on your insurance; however, the benefits quoted to us by your insurance company are not a guarantee of payment. As a courtesy to you, our office will complete any necessary insurance forms at no additional charge, and file them with your insurance company to help you collect. It is to be understood and agreed that any services rendered are charged to you directly and you are personally responsible for payment of any non-covered services, deductibles or co-pays. You may also pay the full amount due each day thereby qualifying for our Time of Service discounted fees. You may then submit the bill to your insurance carrier for reimbursement.

“ON THE JOB” INJURY (Worker’s Compensation)
At this time, we are not providers for any Worker's Compensation insurance plans. If you are injured on the job, and want your care paid for by your employer, you will need to be cared for by a physician in the insurance network. We apologize for any inconvenience.

PERSONAL INJURY OR AUTOMOBILE ACCIDENTS
Please present your auto insurance card, your health insurance card, and tell us if you have retained an attorney.
There are four options available to the PI patient:
1. Pay cash for your care and we will submit reports whenever necessary.
2. We will bill (accept assignment) from the Med Pay portion of your auto insurance.
3. We will accept a Letter of Protection or Doctor’s Lien from an attorney and await payment at the time of settlement as long as you remain an active patient.
4. We will bill your standard health insurance plan and you will be responsible for all co-pays and deductibles as they are incurred.
Although you are ultimately responsible for your bill, we will wait for settlement of your claim for up to six months after your care is completed. Once the claim is settled or if you suspend or terminate care, any fees for
services are due immediately.

MEDICARE
We do accept assignment from Medicare. The check is usually sent directly to our office in payment of the services that Medicare will cover which for Chiropractors is ONLY manual manipulation of the spine. Medicare pays 80% of the allowable fee once the deductible has been met. You are required to pay the deductible and the remaining 20%. All other services we provide are NON-COVERED. These services include, but are not limited to, examinations, therapies, orthotics, supports, and/or nutritional supplements. Medicare patients are fully responsible for charges of non-covered services. Secondary insurance may or may not pay for these noncovered services. Our office completes and files the forms for Medicare at no charge.

SECONDARY INSURANCE
Please inform us of any secondary insurance you may have. We will assist you if you need help in filing.

FLEX SPENDING ACCOUNTS/MEDICAL SAVINGS ACCOUNTS
Please inform us if you have a medical savings account, sometimes known as a 'flex plan'. We will be happy to provide you with a statement of your charges for reimbursement.

INSURANCE FORMS/PAYMENT
If you receive any correspondence from your insurance carrier pertaining to the care you have received at this office or a request for more information regarding your care, please bring it in as soon as possible. It is very important that we keep your file as up-to-date as possible. Occasionally, either by mistake, or due to provisions in your policy, the check issued by the insurance company for payment of services rendered in our office may come to you instead of our office. If you should receive any unexpected check in the mail, please contact us to see if it does represent payment of your bill here.

I have read and understand the payment policy of Green Chiropractic. I understand that my insurance is an arrangement between myself and my insurance company, NOT between Green Chiropractic and my insurance company. I request that Green Chiropractic prepare the customary forms at no charge so that I may obtain insurance benefits. I also understand that if my insurance does not respond within 60 days, or if I suspend or terminate my schedule of care as prescribed by the doctors at Green Chiropractic that fees will be due and payable immediately.
Signature of Patient (or Guardian if minor)*

Clear
Patient/Guardian?*
Date*

MonthDayYear
Date
Should be Empty:

Green Chiropractic Intake Forms

Patient Information

Medical Data

Patient Health Information Consent Form

Informed Consent

Financial Policy