• Patient Information Form

  • Patient Information

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  • Emergency Contact Information

  • Insurance Information

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  • Referral/Purpose

  • AUTHORIZATION AND RELEASE: I authorize payment of insurance benefits directly to the chiropractor or chiropractic office. I authorize the doctor to release all information necessary to communicate with personal physicians and other healthcare providers and payers and to secure the payment of benefits. I understand that I am responsible for all costs of chiropractic care, regardless of insurance coverage. I also understand that if I suspend or terminate my schedule of care as determined by my treating doctor, any fees for professional services will be immediately due and payable.

    The patient understands and agrees to allow this chiropractic office to use their Patient Health Information for the purpose of treatment, payment, healthcare operations, and coordination of care. We want you to know how your Patient Health Information is going to be used in this office and your rights concerning those records. 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. If there is anyone that you do not want to receive your medical records, please inform the office.

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  • Case History

  • Females Only

  • Past History

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  • Social History

  • Family History

  • Additional Questions

  • Patient Health History

    Have you ever (at any time) experienced any of the following?

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  • Do you currently have any of the following?

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  • Current Treating Physicians

  • Insurance Assignment & Personal Balance

     

    Insurance Assignment: Our Insurance Assignment Program is designed to keep your out-of-pocket expenses to a minimum. As a courtesy to you, we will bill your insurance carrier on your behalf and wait up to 90 days for payment. Please remember, however, that you are ultimately responsible for payment.

     

    Personal Balance: Estimated personal portions are paid at the time of service.

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