Workers Compensation

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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
Workers Compensation Insurance Name
Workers Compensation Insurance Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Utilization Review Phone Number

Area CodePhone Number
Utilization Review Fax Number

Area CodePhone Number
MedPay:
Claim #
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

Worker's Compensation Policy
If you have been involved in an on-the-job injury you are entitled to receive Medical/Chiropractic treatment. The injured party, in most instances, is allowed freedom of choice in selection of a doctor.

To activate you claim you must do the following:

1.      Report your injury and complete an accident report and have it on record with your employer.

2.      Furnish this office with all the pertinent information that relates to the accident. Specifically:

·         Provide this office with the name, address, contact person and phone number of your employer.

·         Provide this office with the name, address, contact person, phone number and claim number of your employer’s worker’s compensation insurance carrier.

·         If you seek legal counsel, please provide this office with the name, address, contact person and phone number.

Failure to complete the above steps can result in your being personally responsible for the payment of services rendered by this office.

The worker’s compensation carrier will be notified of your treatment plan with our office and will be billed directly. Payment for services rendered will be paid directly to this office. If the carrier denies your claim or refuses to pay your bill, it will become your responsibility to make payment. Charges for missed appointments will NOT be billed to the insurance carrier and are fully your responsibility with this office.
By signing, I have read, understand and agree to the above workers compensation policy.*

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Name*

First NameLast Name
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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Patient Information

Insurance Information

Health Insurance

Attorney

Worker's Compensation Policy

Informed Consent

HIPAA Permissions

Appointment Policy