MVA Patient Forms

I, hereby request and consent to the performance of any services provided to me whether by a licensed chiropractor, acupuncturist, massage therapist, physical therapist or licensed instructor on behalf of my care to conduct treatments that consist of various forms of adjustments or procedures, including but not limited to various modes of physiotherapy, physical therapy, massage therapy, manual therapy, spinal decompression therapy, radial pressure pulse, cupping, ems training, body ems slimming, class IV laser therapy and diagnostic imaging on me (or on the patient named below, for whom I am legally responsible) by the recommended of either chiropractic, acupuncturist, massage therapist and / or other licensed physician or practitioner whom now or in the future will treat me while employed by, working or associated with or serving as backup for the doctor of desired treatment, including those working at the clinic or office listed above or any other office or clinic. I have had the opportunity to discuss with the treating provider / or with other office or clinic personnel regarding the nature and purpose of treatment and other procedures.

I understand that results are not guaranteed. I understand and am informed that, as in the practice of medicine, in the practice of chiropractic, acupuncture, massage therapy or any other service provided to me that there are some risks in treatment, including, but not limited to fractures, dislocations, strokes and sprains. I do not need or expect the doctor or treating physician to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the procedure which the doctor feels at the time, based upon the then known, is in my best interests. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intended this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I may seek treatment.

SIGNATURE ON FILE
I authorize use of this information on all my insurance submissions. I authorize release of information to all my insurance companies. I understand that I am responsible for all my bills. I authorize my doctor to act as my agent in helping me to obtain payment from my insurance company. I authorize payment directly to my doctor. I permit a copy of this authorization to be used in place of the original. I authorize that I am responsible for payment of an office visit on all missed appointments lacking a 24 —hour cancel notice.

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that the doctor's office will prepare any necessary medical reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to the doctor's office will be credited to my account on behalf of my receipt. However, I clearly understand and agree that all services rendered to me will be immediately due and payable to Body of Beverly Hills Wellness, Inc I also understand that if I suspend or terminate my care and treatment any fees for professional services rendered to me will be immediately due and payable. I undersigned, affirmed, and declared that I have been advised by the doctor's office that the bringing of a fraudulent claim is a crime punishable by imprisonment and / or fine, and that the doctor's office will not treat and / or be part of such fraudulent claims and held responsible. I hereby authorize the doctor to examine and treat any / my conditions as he / she deems appropriate using chiropractic, acupuncture, massage therapy or physical therapy health care personnel. I give authority for all necessary procedures to be performed during my treatment. I also agree that I am responsible for all bills incurred at this office.

PLEASE CHECK OR DESCRIBE:

Below are the list of diseases which may seem unrelated to the purpose of your appointment, However, these questions must be answered carefully as these problems can affect your overall course of care. 

CHECK ANY OF THE FOLLOWING YOU HAVE HAD THE PAST 6 MONTHS:

FEMALES ONLY:

FAMILY HISTORY:

Please answer the questions below. If you don't know the answer to any of the questions, do not answer that question.

4. Time/Speed/Damage

7. Body Position, etc.

8. Additional accident information

9. During the accident:

10. After the accident:

11. Emergency Room?

12. Treatment History:

Fill in the doctor(s) seen prior to your first visit to this office.

1. Description of Accident/Injury/Onset*

*If it is an automobile accident, you can go to the next page. If you would like to describe it more fully, use the boxes above and below to fully describe your accident, injury or onset.

2. During and after accident details

Rate your current difficulties, resulting from your accident/illness, with regard to the various activities listed below. Use the following 1 to 5 scale.

Select the appropriate number that most closely describes your current degree of difficulty:

1="I can do it without any difficulty"

2="I can do it without much difficulty, despite some pain"

3="I manage to do it by myself, despite marked pain"

4="I manage to do it, despite the pain, but only if I have help"

5="I cannot do it all, because of the pain"

Only fill in areas affected.

Difficulties with Self Care and Personal Hygiene Activities

Difficulties with physical activities

Difficulties with Functional Activites

Difficulties with Social and Recreational Activities

Difficulties with Travelling 

Use the following 1 to 5 scale to describe the difficulties below:

1="This area is not affected by my codition"

2="This area is slightly affected by my condition"

3="My condition moderatley restricts my ability in this area"

4="My condition seriously limits my ability in this area"

5="My condition prevents me from using this ability"

Difficulties with Different Forms of Communication

Difficulties with the Senses

Difficulties with Hand Functions

Difficulties with Sleep and Sexual Function

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Kaliko Chiropractic, Inc DBA Body of Beverly Hills Wellness, Inc is required, by law, to maintain the privacy and confidentiality of your protected health information and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information.

Disclosure of Your Health Care Information
Treatment: We may disclose your health care information to other healthcare professionals within our practice for the purpose of treatment, payment, or healthcare operations.
Payment: We may disclose your health information to your insurance provider for the purpose of payment or health care operations. Personal Injury: We may disclose your health information as necessary to comply with State Personal injury Laws.
Emergencies: We may disclose your health information to notify or assist in notifying a family member, Or another person responsible for your care about your medical condition or in the event of an emergency or of your death.
Public Health: As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury, or disability, reporting child abuse or neglect, reporting domestic violence, reporting to the Food and Drug Administration problems with products and reactions to medications, and reporting disease or infection exposure.
Judicial and Administrative Proceedings. We may disclose your health information in the course of any administrative or judicial proceeding.
Law Enforcement. We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena, and other law enforcement purposes.
Deceased Persons. We may disclose your health information to coroners or medical examiners.
Organ Donation: We may disclose your health information to organizations involved in procuring, banking, or transplanting organs and tissues.
Research. We may disclose your health information to researchers conducting research that has been approved by an Institutional Review Board.
Public Safety. It may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public.
Specialized Government Agencies. We may disclose your health information for military, national security, prisoner and government benefits purposes.
Marketing: We may contact you for marketing purposes or fundraising purposes.
Change of Ownership. If Kaliko Chiropractic, Inc DBA Body of Beverly Hills Wellness, Inc is sold or merged with another organization, your health information/ record will become the property of the new owner.
Your Health Information Rights

• You have the right to request restrictions on certain uses and disclosures of your health information. Please be advised, however, Kaliko Chiropractic, Inc DBA Body of Beverly Hills Wellness, Inc that is not required to agree to the restriction that you requested.
• You have the right to have your health information received or communicated through an alternative method or sent to an alternative location Other than the usual method of communication or delivery, upon your request.
• You have the right to inspect and copy your health information.
• You have a right to request that Kaliko Chiropractic, Inc DBA Body of Beverly Hills Wellness, Inc amend your protected health information. Please be advised, however, that Body of Beverly Hills Wellness, Inc is not required to agree to amend your protected health information. If your request to amend your health information has been denied, you will be provided with an explanation of our denial reason(s) and information about how you can disagree with the denial.
• You have a right to receive an accounting of disclosures of your protected health information made by Kaliko Chiropractic, Inc, DBA Body of Beverly Hills Wellness, Inc
• You have a right to a paper copy of this Notice of Privacy Practices at any time upon request.

Changes to this Notice of Privacy Practices
Kaliko Chiropractic, Inc DBA Body of Beverly Hills Wellness, Inc reserves the right to amend this Notice of Privacy Practices at any time in the future and will make the new provisions effective for all information that it maintains. Until such amendment is made, Body of Beverly Hills Wellness is required by law to comply with this Notice. Kaliko Chiropractic, INC DBA Body of Beverly Hills Wellness, Inc is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about your privacy rights, please contact Kaliko Chiropractic, Inc DBA Body of Beverly Hills Wellness, Inc by emailing at contact@BodyofBeverlyHillsWellness.com or visit our website https://www.bodyofbeverlyhillswellness.com/ any complaints about your privacy rights, or how Kaliko Chiropractic, Inc DBA Body of Beverly Hills Wellness, Inc has handled your health information should be directed to us by the email at contact@BodyofBeverlyHillsWellness.com. You may make an appointment for a personal conference in person or by telephone within (2) working days. If you are not satisfied with the way this office handles your complaint, you may submit a formal complaint to: DHHS, Office of Civil Rights 200 Independence Avenue, S.W. Room 509F HHH Building, Washington, DC 20201 This notice is effective from the date below. I have read the Privacy Notice and understand my rights contained in the notice. By way of my signature, I provide Kaliko Chiropractic, Inc DBA Body of Beverly Hills Wellness, Inc with my authorization and consent to use and disclose my protected health care information for the purposes of treatment, payment and health care operations as described in the Privacy Notice.