I certify that I, and/or my dependent(s), have insurance coverage with Name of Insurance Company and assign directly to Dr. Name all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.
Rate Pain 1(mild) to 10(severe)
Please select "Yes" or "No" to indicate if you have had any of the following:
Injuries/Surgeries you have had
INSTRUCTIONS: Please select the number (o= no pain; 10=unbearable pain) that best describes the question being asked. If you have more than one complaint, please answer each question for each individual complaint and indicate which score is for which compalint.
Use the symbols listed below, mark on the two drawings below the areas on your body where you feel the described sensations:
Numbness === Hot Burning xxx
Dull ache ooo Sharp Stabbing ///
Pins and Needles +++
Welcome to the office! We are honored you have chosen this office to provide Chiropractic care to you and/or your family. Be assured that we will do everything in our power to give you a very positive experience. Our aim is to get you well and help you meet your health goals...period. Our office mission and guarantee:
“If we can help you, we will tell you. If we cannot help you,we will tell you that as well and make the proper referral”
Notice of Privacy Practices
In accordance with the Protected Health Information Act (PHI) our office will, without asking yourexpress consent or authorization, use and disclose your PHI for the purposes of:
You have the right to revoke, request special limits or conditions, to receive communication by more confidential means or at alternate locations, to inspect and copy your PHI, and to amend your PHI.
Copies of the NPP may be obtained upon request. Our office strives to maintain HIPAA compliance.
I understand that by signing the above statement I have been notified of my rights in compliance with HIPPA regulations. I have been advised that I may request a complete copy of these rightsavailable through the HIPAA officer at this location.
If you ever need anything, just ask one of our staff and call me directly at 614-898-0787 I'd love your feedback on how we are doing in terms of meeting, hopefully exceeding your expetations so that you will refer your friends, family and co-workers. The greatest compliment we can receive is the trust placed in us via your referrals. We value that trust! Again, welcome to our office