blockchiropracticcenter.com - Chiropractic Intake Form

CHIROPRACTIC REGISTRATION

PATIENT INFORMATION
Date:

MonthDayYear
Date
Patient Name:

First NameLast Name
Age:
Date of Birth:

MonthDayYear
Date
Sex:

MF
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Martial status:

SingleMarriedWidowedSeparatedDivorced
Patient SS#
Occupation
Employer
Employer Address
Spouse's Name
Birth Date

MonthDayYear
Date
Spouse's SS#
Spouse's Occupation
Spouse's Employer
How did you hear about us?
If referred, who:
*We do require a 48-hour for all cancellations and you will be charged a $70 cancellation fee if you do NOT cancel within 24-hours of your scheduled appointment.
INSURANCE INFORMATION
Who is responsible for this account?
Relationship to Patient:
Insurance Co.
Insurance ID#
Is patient covered by additional insurance?

YesNo
Subscriber's Name:

First NameLast Name
Subscriber's Birth Date:

MonthDayYear
Date
SS#
PHONE NUMBERS
Home
Please enter a valid phone number.
Work
Please enter a valid phone number.
Ext
Cell
Please enter a valid phone number.
Cell Carrier
(Indicate cell carrier if appointment reminder text messages can be sent to that cell number)
Email Address
(Please provide email as we communicate with our patient through email)
EMERGENCY CONTACT
Name

First NameLast Name
Relationship
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
PATIENT CONDITION
Chief complaint:
How long:
How often:
Severity of pain: (scale of 1-10)

1

2

3

4

5

6

7

8

9

10

1 is No Pain, 10 is Worst Pain
Quality of pain:(please select)

SharpDullAchingBurningOther
What caused this:
What treatments have you tried:
Does it interface with your work, sleep, daily routine, or recreation? If so, how:
Have you had chiropractic care before?

YesNo
If yes, where/who:
Any concerns or fears about chiropractic care?

YesNo
If yes, what:
ACCIDENT INFORMATION
Is condition due to an accident?

YesNo
If so, please provide date
Type of Accident?

AutoWorkHomeOther
Severity of pain:(scale of 1-10)

1

2

3

4

5

6

7

8

9

10

1 is No Pain, 10 is Worst Pain
Quality of pain:

SharpDullArchingBurningOther
Have you reported this accident?(please circle)

YesNo
If yes, to whom?

Auto InsuranceEmployerWork CompOther
Attorney name (If applicable)
TREATMENT INFORMATION
What treatments have you already received for your condition?

MedicationSurgeryPhysical TherapyChiropractic CareAcupunctureMassageNoneOther
Name of Practitioner and last date of treatment
Last Date of Spinal X-ray

MonthDayYear
Date
Physical Exam

MonthDayYear
Date
Blood Test

MonthDayYear
Date
MRI

MonthDayYear
Date
CT Scan

MonthDayYear
Date
Primary care Physician name and address
Are you under the care of any other health care professionals?(please circle)

YesNo
Who?
*Please sign here if you would like a report to be sent to the above named Doctor:
Patient:
Date:

MonthDayYear
Date
PERSONAL INFORMATION
Exercise

NoneModerateDailyHeavy Lifting
Type of exercise
Allergies:
Caffeine intake: (how much)
Work Activity

SittingStandingLight LaborHeavy LaborComputer Work
Do you smoke?

YesNo
How much?
Do you drink alcohol?

YesNo
How often?
High stress level?

YesNo
Reason:
Please check to indicate if you have had any of the following:

Aids/HIVAlcoholismAllergy ShotsAnemiaAnorexiaAppendicitisArthritisAsthmaBleedingDisorderBreast LumpBronchitisBulimiaCancerCataractsChemicalDependencyChicken PoxDiabetesFracturesGlaucomaGoiterGonorrheaEmphysemaEpilepsyFibromyalgiaGastrointestinal IssuesHeart DiseaseHepatitisHerniaHerniated DiscHerpesHigh CholesterolHigh Blood PressureJoint ReplacementKidney DiseaseLiver DiseaseLupusOsteoarthritisOsteoporosisPacemakerParkinson'sPinched NervePneumoniaPolioProstate ProblemProsthesisPsychiatric CareMeaslesMigrainesMiscarriageMononucleosisMultiple SclerosisRheumatoid ArthritisRheumatic FeverScarlet FeverStrokeSuicide AttemptSwine FluTension HeadacheThyroid ProblemsTonsillitisTuberculosisTumors, GrowthsTyphoid FeverUlcersVaginal InfectionVenereal DiseaseWhooping Cough
Other:

Please select if applicable:

	Yes	No	Describe
Medications
Surgeries
Broken Bones
Dislocations
Falls
Injuries
Hospitalizations

Patient/Guardian Signature:

Clear
Date:

MonthDayYear
Date

Block Chiropractic and Rehabilitation Center, LLC 3901 National Drive, Suite 250 Burtonsville, MD 20866 301-476-7575 301-476-7730 fax www.blockchiropracticcenter.com
I Name hereby authorize the release of any and all medical records pertaining to my current state of health to be released to my chiropractor, Dr. Debra Block of Block Chiropractic and Rehabilitation Center LLC. Please send all diagnostic results, lab work, and history information that you have on record for me.
Patient Name:

First NameLast Name
Patient Signature:

Clear
Date:

MonthDayYear
Date
Date of Birth:

MonthDayYear
Date
Social Security #:
Doctor Signature:

Clear
Date:

MonthDayYear
Date
I Name hereby allow Dr. Debra Block Chiropractic to share my healthcare information with the following individuals.

	Contact Name	Relationship to Patient	Phone Number
1
2
3

Patient Signature:

Clear
Date:

MonthDayYear
Date

Patient Privacy Consent Form (HIPAA)
To our valued patients:

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.

The Department of Health and Human Services has established a 'privacy rule' to help insure that personal health care information about the patient regarding treatment, payment, and health care operations, remains private.

As our patient, we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide the minimum necessary information to only those we feel are in need of your health care information and information about treatment, payment, and health care operations, in order to Provide health care that is in your best interest.

We also want you to know that we support your full access to your personal medical records. You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose Personal Health Information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or a previously signed consent. If you have any objections to this form, please ask to speak to our HIPAA Compliance Officer.

The misuse of PHI has been identified as a national problem causing patients inconvenience, aggravation, and time. We want you to know that all people who work at Block Chiropractic & Rehabilitation Center, LLC strive to understand and comply with government rules and regulations regarding the Health Insurance Portability and Accountability Act (HIPAA) with particular emphasis on the 'privacy rule.' We also strive to achieve the very highest standards of ethics and integrity in performing services for our patients.

It is our policy to properly determine appropriate uses of PHI in accordance with the governmental rules, law and regulations. We want to insure that we never contribute to the growing problem of improper disclosure of PHI. We strive to be compliant and adhere to federal and state health care program requirements. We also know that we are not perfect. Because of this fact, our policy is to listen to our patients if they feel that anything in our office compromises our policy of integrity and if they have suggestions to help us better achieve the goals of PHI privacy.

Thank you for being one of our valued patients.
Name:
Signature:

Clear
Date:

MonthDayYear
Date

AUTHORIZATION AND ASSIGNMENT
Section A: Authorization and Assignment

Medical Information Release Authorization

I hereby authorize release of all records pertaining to my medical history, treatment or payment information which is required in the processing of applications for payment of benefits, to Block Chiropractic & Rehabilitation Center, LLC and Dr. Debra Block.

Insurance Information Release Authorization

I hereby authorize Block Chiropractic & Rehabilitation Center and Dr. Debra Block to release to my referring doctor, any other doctor(s) I am a patient of, and insurance company any information concerning my physical condition or treatment.

Late Fees, Breach, Costs and Attornevs Fees, Venue

If a credit card payment is decline or a balance is otherwise owed and the balance is not paid within thirty (30) days of billing, interest shall begin to accrue at six percent (6%) per annum. A separate fee for a returned (bounced) check equals the amount the bank charges Block Chiropractic & Rehabilitation Center, LLC plus $25.00. In addition, a late fee shall be added to the account up to $5.00 per month, or up to ten percent (10%) per month of the payment amount which is past due, whichever is greater. If an account is turned over to an attorney for collection, the patient is responsible for payment of all attorney's fees actually incurred to collect the amount due hereunder, even if the attorney's fees exceed the amount to be collected, plus interest, late fees and the actual costs of collection, whether or not a lawsuit is filed. In the event that a lawsuit is filed, said action shall be brought in the courts of Montgomery County, Maryland.

Binding Obligation, Entire Agreement

All signatories to this Agreement warrant that they have full and complete authority to enter into this Agreement and to sign said Agreement on behalf of themselves or the entity on whose behalf they are signing or both. This Agreement shall constitute the entire Agreement between the parties hereto, and no variance or modification thereof shall be valid and enforceable except by another agreement, in writing, execute and approved in the same manner as this Agreement.
Date

MonthDayYear
Date
Patient Signature

Clear
Date

MonthDayYear
Date
Block Chiropractic & Rehabilitation Center, LLC
Section B: Authorization and Waiver

Assignment of Insurance Benefits or Legal Claim

In the case of an insurance or legal claim, I hereby assign and transfer to Block Chiropractic & Rehabilitation Center, LLC and Dr. Debra Block, all proceeds of any such claim and authorize the insurance company or my attorney to pay all sums due to Block Chiropractic & Rehabilitation Center, LLC and Dr. Debra Block from said proceeds before paying the balance of said proceeds to me. I further authorize direct payment of medical benefits from my insurance company or attorney to Block Chiropractic & Rehabilitation Center, LLC and Dr. Debra Block, for all services rendered. I understand that I am financially responsible for any balance not covered by my insurance or a third party claim, and hereby assume full responsibility for all charges incurred for professional services rendered by Block Chiropractic & Rehabilitation Center, LLC and Dr. Debra Block. If any service is denied by my insurance company, I agree to be personally financially liable for payment for said services.

Waiver

For the purposes of assigning any insurance benefits or legal claims, I hereby waive the statute of limitations with respect to a third party cause of action.

Binding Obligation, Entire Agreement

All signatories to this Agreement warrant that they have full and complete authority to enter into this Agreement and to sign said Agreement on behalf of themselves or the entity on whose behalf they are signing or both. This Agreement shall constitute the entire Agreement between the parties hereto and no variance or modification thereof shall be valid and enforceable except by another agreement, in writing, executed and approved in the same manner as this Agreement.
Date

MonthDayYear
Date
Patient Signature

Clear
Date

MonthDayYear
Date
Block Chiropractic & Rehabilitation Center, LLC

Financial Policies
The following is the summary of our payment policies and what we expect from all our patients.

Payments:

All payment is expected at time services are rendered unless other arrangements have been made in advance. This includes but is not limited to applicable coinsurance, copayments, and deductibles for participating insurance companies. Block Chiropractic and Rehabilitation Center, LLC accepts cash, personal checks, Visa, Mastercard, and Discover. There is a $25 service charge plus the bank fee for returned checks.

Patients with an outstanding balance 60 days or more overdue must make arrangements for payment prior to scheduling appointments. We realize that certain patients do experience financial hardships. In such circumstances the patient or patient's representative may request a financial consultation with the office manager to discuss other arrangements. Any action taken in response to any request is at the sole discretion of Block Chiropractic and Rehabilitation Center, LLC.

Insurance:

Block Chiropractic and Rehabilitation Center, LLC bills participating insurance companies as a courtesy to the patient. The patient is expected to pay all deductibles, copayments, and coinsurance at the time of service. We will also verify insurance benefits as a courtesy to the patient, however, it is the patient's responsibility to understand his/her policy's benefits.

We will also bill secondary insurance companies as a courtesy to the patient. Again, it is the patient's responsibility to communicate with his/her primary insurance company for any bills to be forwarded to the secondary insurance company.

HMOs:

If the patient's insurance policy is an HMO and the patient is in need of a referral prior to his/her visit, it is the patient's responsibility to obtain that referral prior to coming to the first visit at Block Chiropractic and Rehabilitation Center, LLC.

Missed appointments:

Missed appointments represent a cost to Block Chiropractic and Rehabilitation Center, LLC and to other patients who could have been seen during the time set aside for the appointment. Cancellations are required at least 24 hours prior to the appointment. Block Chiropractic and Rehabilitation Center, LLC reserves the right to charge for missed or late-canceled appointments. Block Chiropractic and Rehabilitation Center's fee for a missed appointment without adequate notice is $70. Excessive abuse of scheduled appointments may result in discharge from the practice.

Credit Card on File policy:

At Block Chiropractic and Rehabilitation Center, LLC we require all patients to keep a credit card or debit card on file as a method of payment for the portion of services that insurance does not cover but for which the patient is liable. The credit card will also be charged for any missed appointments without 24 hours prior notice of cancellation and for any unpaid non-insurance services.

All patients' credit card information will be kept confidential and secured. The credit card will only be charged after the insurance claim has been filed and processed by the patients' health insurance company. Block Chiropractic and Rehabilitation Center, LLC will bill the patient prior to charging the card. Any bill that is left unpaid for 30 days will be charged to the credit/debit card on file; however, Block Chiropractic and Rehabilitation Center, LLC will first contact the patient to advise of the upcoming transaction.

I authorize Block Chiropractic and Rehabilitation Center, LLC to charge the portion of my bill that is my financial responsibility to my credit or debit card as per the above policy.

I, the undersigned, authorize Block Chiropractic and Rehabilitation Center, LLC to charge my credit or debit card for any balance due for services rendered that my insurance company identifies as my financial responsibility or non-insurance services that remain unpaid after 30 days. This authorization will remain in effect until I cancel this authorization. To cancel, I must give a 30 day notification to Block Chiropractic and Rehabilitation Center, LLC in writing and the account must be in good standing.
Name
Date

MonthDayYear
Date
Signature

Clear
Relationship to Patient
PLEASE GIVE CREDIT CARD TO FRONT DESK
Billing Address for credit card
Delinquent Accounts:

Block Chiropractic and Rehabilitation Center, LLC reserves the right to utilize a collection agency if, at its discretion the patient should fail to fulfill his/her obligation. Patient agrees that the responsibility for said balance plus fees charged by the collection agency for the cost of collection will be the patient's responsibility.

I have read and understand the financial policies of Block Chiropractic and Rehabilitation Center, LLC and agree to be bound by same.
Signature of insured or Authorized representative:

Clear
Date

MonthDayYear
Date

CONSENT FOR TREATMENT
I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures including various modes of physical therapy diagnostic x-rays on me, or on the patient named below, for whom I am legally responsible by the doctor and/or other licensed doctors of chiropractic who now or in the future teat me while employed by working or associated with serving as back up for the doctor of chiropractic, including those working at clinic or offce listed or any other office or clinic.

I have had an opportunity to discuss with the doctor of chiropractic and/or with other office or clinic personnel, the nature and purpose of chiropractic adjustments and other procedures. I understand that results are not guaranted.
Patient's Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

CHIROPRACTIC REGISTRATION

INSURANCE INFORMATION

PHONE NUMBERS

EMERGENCY CONTACT

PATIENT CONDITION

ACCIDENT INFORMATION

TREATMENT INFORMATION

PERSONAL INFORMATION

Block Chiropractic and Rehabilitation Center, LLC 3901 National Drive, Suite 250 Burtonsville, MD 20866 301-476-7575 301-476-7730 fax www.blockchiropracticcenter.com

Patient Privacy Consent Form (HIPAA)

AUTHORIZATION AND ASSIGNMENT

Financial Policies

CONSENT FOR TREATMENT