Personal Injury

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Patient Information
Patient Information

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Name

First NameLast Name
Referred by
Date of Incident

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Today's Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone

Area CodePhone Number
Secondary Phone

Area CodePhone Number

Insurance Information
Insurance Information
Name of Insured

First NameLast Name
Driver or Passenger?

DriverPassenger
Insurance Name
MedPay:
Claim #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Adjustor's Name

First NameLast Name
Adjustor's Phone #

Area CodePhone Number
Adjustor's Fax #

Area CodePhone Number
Follow up - Payment Instructions faxed
Date faxed

MonthDayYear
Date
Notes/ Instructions for billing

Health Insurance
Health Insurance
Insurance Name
Policy #
Insurance Phone # from card

Area CodePhone Number
Chiropractic Benefits

Attorney
Attorney
Attorney Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Name (if different from attorney)

First NameLast Name
Phone Number

Area CodePhone Number
Fax #

Area CodePhone Number
Lien Sent
Date Lien Sent

MonthDayYear
Date
Notes/ Instructions for follow up

Notice of Irrevocable Lien and Assignment of Benefits Authorization for Release of Treatment Records Legal and Equitable Lien- Attorney's Acceptance
Patient Name

First NameLast Name
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Insured (PIP)

First NameLast Name
Name of Insurer (PIP)
Date of Injury/ Illness

MonthDayYear
Date
Name of Insured (BI)

First NameLast Name
Name of Insurer (BI)
Name of Law Office and Attorney
In consideration of the agreement of the facility and provider(s) named above to provide me with injury treatment services, I hereby to the extent of my treatment bills irrevocably assign to my healthcare facility and to my Provider(s) all my right, title and interest to and in all applicable insurance and indemnification reimbursement benefits of applicable insurance companies including but not limited to: Automobile PIP (Personal Injury Protection) coverage; Medical Payment Coverage, BI (Bodily Injury) liability proceeds and health care coverage to which I may be entitled to pay my Provider(s) for services rendered to treat me on and after the above date in connection with my injury or illness.

I further grant to my Provider an irrevocable Equitable Lien and an Official Legal Lien as set forth in Ch 111S70A through Ch111S70D Massachusetts General Laws to and in any insurance benefits that may be due me and I furthermore authorize my Provider(s) to provide my attorney and any applicable insurance companies involved with a full report concerning my condition and treatment, including but not limited to office notes, dates of visits, and charges incurred.

I hereby authorize and direct any and all applicable insurance companies to make immediate payment directly to my said Provider(s) for all benefits and sums due me that may be due him or her upon receipt by you of my Provider’s itemized statement for treatment services rendered to me.

It is further agreed that payment by any insurance company involved as herein directed to my Provider of any itemized statement shall be considered the same as if paid by the insurer directly to me.

I am aware that I remain personally responsible to my provider for the full amount of my unpaid treatment bills and further direct my Attorney representing me to withhold from the proceeds upon any final settlement or final disposition of my case an amount equal to that to pay any outstanding unpaid balance of my bills. This includes any balance due as a result of an independent medical exam that discontinued my personal injury protection benefits and/or my medical payments benefit.
By signing, I have read and understand the Notice of Irrevocable Lien and Assignment of Benefits Authorization for Release of Treatment Records Legal and Equitable above:*

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Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Today's Date*

MonthDayYear
Date

Informed Consent
Informed Consent
Please read this consent form and discuss it, if you would like to, with your doctor, and then sign where indicated at the bottom of the page. Clinicians who use spinal manual therapy techniques, such as joint manipulation, mobilization, or adjustment are required to inform their patients that there may be some risks associated with such treatment.

Treatments provided at this clinic, including the spinal adjustment, manipulation and/or mobilization, have been the subject of much research conducted over many years and have been demonstrated to be appropriate and effective treatments for many common forms of spinal pain, pain in the shoulder/arms/legs, for headaches and other neuromuskulosketetal symptoms. Treatment provided at this clinic may also contribute to your overall well-being. The risk of injury or complication from manual treatment is substantially lower than the risk associated with many standard medical treatments given for the same forms of musculoskeletal pain, such as muscle relaxing drugs, anti-inflammatory drugs such as aspirin, or pain pills. The most frequent risk that occurs in a chiropractic clinic is from burns associated with hot packs. Our office does not even use hot packs. Rarely some patients have reported muscle or ligament sprains or strains or rib fractures following an adjustment, however, our low amplitude techniques make that extremely improbable. There have been some “reports” of disc injury following an adjustment, however, there is NO scientific study that has ever demonstrated that such injuries are caused, or may be caused, by adjustments or manipulative techniques. In fact there is much scientific evidence to the contrary. Chiropractic adjustments offer disc patients significant relief and a speedier recovery without the need to resort to surgery. There have also been “reports” of injuries to a vertebral artery following neck adjustments. Usually these patients have a predilection for vertebral artery dissection prior to their chiropractic visit. These patients are already at risk for stroke under many positional activities. They are already at risk for serious neurological injury and impairment, and are no more likely to have such an incident in a chiropractic office than they are in a medical clinic or a beauty salon. This form of complication is astronomically rare occurring about 1 in 12-50 million and has little or no correlation with the chiropractic adjustment.

Your clinician will evaluate your individual case; provide an explanation of care and a suggested treatment plan, or alternatively a referral for outside consultation and/or further medical evaluation if deemed necessary.

Acknowledgement: I acknowledge that I have read, discussed, or have been given the opportunity to discuss, with my clinician the nature of chiropractic treatment in general and my treatment in particular as well as the contents of the consent.

Consent: I consent to the chiropractic treatment(s) offered or recommended to me by my clinician, including joint adjustment or manipulation or mobilization to the joints of the spine (neck and back), pelvis and extremities (shoulder, upper limbs and lower limbs). I intend this consent to apply to all my present and future treatments at this clinic.
Type your name to acknowledge and consent to chiropractic treatment:*

First NameLast Name
Date*

MonthDayYear
Date
Signature*

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HIPAA Permissions
HIPAA Permissions
PERMISSION TO COMMUNICATE (HIPAA)

We are very concerned with protecting your privacy, especially in matters that concern your personal health information. In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). We are required to supply you with a copy of our privacy policies and procedures. We encourage you to read this document carefully, for it outlines the use and limitations of the disclosure of your health information and your rights as a patient. If you ever have and questions or concerns regarding the use of dissemination of your personal health information, we would be happy to address them.

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION (HIPAA)

I hereby authorize Dr. Debs or his assigned staff members to release information contained in my medical record to any and all insurance carriers from whom I may be due benefits, to my primary care physician or other healthcare providers associated with my treatment, to the state chiropractic society in the event their assistance is needed on my behalf, and to my attorney of record (if an attorney is involved).
Type your name for our HIPAA permissions:*

First NameLast Name
Date*

MonthDayYear
Date
Signature*

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Appointment Policy
Appointment Policy
Due to high patient demand, and limited availability of appointment we have instituted a $25.00 NO SHOW FEE. You must give 24 hour notice to cancel appointments. Failure to do so may result in a $25.00 fee charged to your account.

I agree to give 24 hours notice to cancel an appointment. IF notice is not given I understand that there is a $25.00 fee incurred for each occurrence.

I HEARBY CERTIFY that I have read and understand the conditions of this agreement for Professional/Privacy/Financial Services.

I acknowledge that I have been offered a copy of inBalance Chiropractic & Wellness’ Notice of Privacy Practices for Protected Health Information.
Type your name to agree with our Appointment Policy:*

First NameLast Name
Date*

MonthDayYear
Date
Signature*

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Should be Empty:

Patient Information

Insurance Information

Health Insurance

Attorney

Personal Injury Protection Policy

Patient Information

Accident Site

Impact

Illustration of the Accident

Your Vehicle

Other Vehicle

Patient Condition

Treatment

Notice of Irrevocable Lien and Assignment of Benefits Authorization for Release of Treatment Records Legal and Equitable Lien- Attorney's Acceptance

Informed Consent

HIPAA Permissions

Appointment Policy