New Patient Form

New Patient Form

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Date*

MonthDayYear
Date
Email*
example@example.com
Name*

First NameLast Name
Middle Initial*
Age*
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Main Phone Number*
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Social Security Number*
Employer*
Marital Status *
Spouses Name
Spouse's Phone Number
Please enter a valid phone number.
Name of Insurance Company*
Insurance ID #*
Insurance Group #*
Insured Name (Only if different from above)

First NameLast Name
Insured SSN (Only if different from above)
Insured DOB (Only if different from above)

MonthDayYear
Date
Guarantor Name (Only if different from above)

First NameLast Name
Guarantor SSN (Only if different from above)
Guarantor DOB (Only if different from above)

MonthDayYear
Date
Guarantor Address (Only if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who referred you to this office?
Referred by:
Are your complaints related to an accident?*

YesNo
Date of accident:

MonthDayYear
Date
If this is an accident or work related injury, please ask the receptionist for additional forms.

PAYMENT POLICIES FOR MEDICAL PRACTICE

We accept cash, check, Visa, Mastercard, Discover Card, Care Credit and most insurance companies.
If you have insurance, the following apply:

1. It is your responsibility to provide us with the correct information about your insurance company and to follow the rules of your insurance company. 2. You are responsible for paying any deductibles, co-payments or non-covered services. 3. We file group insurance claims. If your insurance company does not approve treatment, you will be responsible for the charged services. In the event of non-payment, you will be responsible for any collec and/or legal fees associated with the collection of the balance due. The collection fee is 25% of the total balance turned over to an outside agency.
I have read all the above terms and hereby assume responsibility for paying any charges according to these terms.
Signature*

Clear
Date*

MonthDayYear
Date

CONSENT FOR TREATMENT, AUTHORIZATION FOR RELEASE OF INFORMATION, AND AUTHORIZATION FOR PAYMENT
CONSENT FOR TREATMENT:

The undersigned hereby consents to standard treatment and routine medical and nursing procedures. I understand this may include, but is not limited to, measurements and procedures to determine the cause of the problem, movement of my spinal vertebrae using hands or instruments designed for this purpose, mild electrical and sound-wave stimulation of the skin surfaces and muscles.
AUTHORIZATION TO RELEASE INFORMATION:

I hereby authorize PC Medical Centers and its designated staff to make records about my personal and physical condition and to maintain this information electronically, by fax transmission, by voice telephone, or by mail. Any and all information contained in my medical records pertaining to a specified period of treatment to my family physician or consulting physician or other healthcare professionals or to my insurance company. I understand PC Medical Centers keeps on file notice of their policies regarding the use of my personal health information and that I may review those policies upon my request. I understand that this must be provided in writing to PC Medical Centers.
AUTHORIZATION FOR PAYMENT:

I hereby authorize PC Medical Centers to receive medical insurance benefits otherwise payable to me for services rendered but not to exceed the balance due of the regular charges provided me for and during this period of treatment. I understand that it is my responsibility to provide PC Medical Centers with timely notification of my insurance coverage. I understand that I am financially responsible to PC Medical Centers for charges not covered by this authorization. I permit a copy of this authorization to be used in place of the original and direct payment of medical insurance benefits directly to PC Medical Centers. In consideration of the services to be rendered I agree to pay for services charged at PC Medical Centers office not paid for by my insurance benefits in accordance with its regular rates and charges for services and goods. Should the account become delinquent and be referred to a collection agency or attorney, I shall pay all reasonable collection expenses, court costs and a reasonable attorney fee.
Any exceptions to this consent, if any: (If none, write "none")*
Signature*

Clear
Date*

MonthDayYear
Date

NOTICE OF PRIVACY PRACTICES

This notice describes how medical information about you may be used and disclosed and how you can get access to the information. Please review carefully. We are required by the Health Insurance Portability & Accountability Act of 1996 (HIPPA) to provide confidentiality for all medical/mental records and other individually identifiable health information in our possession. This notice is to inform you of the uses and disclosures of confidential information that may be made by PC Medical Centers and of your individual rights at PC Medical Centers legal duties with respect to confidential information.
Ways in which we may use and disclose your protected health information:

We may use an disclose at our discretion your medical records for each of the following purposes only: treatment, payment, and health care options.
Treatment:

Means providing, coordinating or managing health care and related services.
Payment:

Means activities such as obtaining payment for the services provided to you.
Health Care Options:

Includes day to day operations regarding you within this practice. We may contact you to provide appointment reminders or other services that may be of interest to you. I will disclose our protected health information to individuals you identify as involved in payment with your care. We will use and disclose your protected health information when required by federal, state, or local law. There are certain situations in health care that may arise where this office is ethically and legally mandated to reveal your protected health information to appropriate persons or agencies even if you do not give permission. These situations include a.) if you threaten bodily harm or death to yourself or another person; b.) if you report your knowledge of physical or sexual abuse of a minor or child, or of an elder over age 65; c.) if we are requested by a court of law to turn over records to the court or if we are ordered to testify regarding those records. Any other uses and disclosures will be made only with your written authorization. You will be provided with an authorization form upon request. A separate form will be needed for each request for release of information. The authorization for release of records is valid until it expires or is revoked. You may revoke authorization in writing at any time and will be honored to the extent that any actions that have already occurred regarding your authorization.
Your signature below indicates you have read and understand the above information regarding protected health information uses and disclosures.
Signature*

Clear
Date*

MonthDayYear
Date

PHOTO/VIDEO RELEASE

Permission to Use Photograph/Video
Permission to Use Photograph/Video

I grant PC Medical Centers, its representatives and employees the right to take photographs of me and my property in connection with the above identified subject. I authorize PC Medical Centers, its assignees and transferees to copyright, use and publish the same in print and/or electronically.

I agree that PC Medical Centers may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.

I have read and understand the above:
Permission to use photograph/video:*

I ConsentI DO NOT Consent
Signature*

Clear

Family Medical History:
Father
Age: blanks Condition: blank
If deceased, cause of deathblank
Mother
Age: blanks Condition: blank
If deceased, cause of deathblank
Siblings
Age: blanks Condition: blank
If deceased, cause of deathblank
Spouse
Age: blanks Condition: blank
If deceased, cause of deathblank
Children
Age: blanks Condition: blank
If deceased, cause of deathblank
Any Additional Relatives
Age: blanks Condition: blank
If deceased, cause of deathblank

New Patient Form

If this is an accident or work related injury, please ask the receptionist for additional forms.

PAYMENT POLICIES FOR MEDICAL PRACTICE

If you have insurance, the following apply:

I have read all the above terms and hereby assume responsibility for paying any charges according to these terms.

CONSENT FOR TREATMENT, AUTHORIZATION FOR RELEASE OF INFORMATION, AND AUTHORIZATION FOR PAYMENT

CONSENT FOR TREATMENT:

AUTHORIZATION TO RELEASE INFORMATION:

AUTHORIZATION FOR PAYMENT:

NOTICE OF PRIVACY PRACTICES

Ways in which we may use and disclose your protected health information:

Treatment:

Payment:

Health Care Options:

Your signature below indicates you have read and understand the above information regarding protected health information uses and disclosures.

PHOTO/VIDEO RELEASE

History of present illness:

Family Medical History:

Indicate which of the below you have experienced in the last 1-2 months.

OFFICE-USE ONLY