Thank you for your interest in our services -- please fill out the New Patient Application form below before your first appointment.

Read this first...

NAVIGATION - do not use the "BACK" button on your browser to go back to a prior page - instead use only the buttons provided at the bottom of each page to navigate.  Using the "BACK" button will take you to a prior webpage and close out the form.

HIPAA COMPLIANCE - this form is HIPAA compliant and uses SSL encryption to transmit your information. If you are concerned about filling in your application online, then please download the PDF version to fill out offline at this link.

MEDICARE PATIENTS - If you are a Medicare patient, then please contact us by telephone at 281-585-3500 for special instructions before proceeding.

This form will require approximately 5-10 minutes to complete.

Please wait for the HealthWorks logo to appear at the top of this page before proceeding...

Thank you.  

Personal Information

25% complete

Insurance/Account Information

Emergency Contact

How Did You Hear About Us?

50% complete

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Almost done... just some Authorization Forms left!

 

OK, we are all done collecting information about your condition and family history - THANKS so much for working your way through that!

Now we just have a few authorization forms for your to initial / sign and then we're finished....

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Treatment Authorization

I hereby authorize HealthWorks Chiropractic and/or Alvin Health treat my condition as they may deem appropriate.

It is understood and agreed the amount paid to HealthWorks Chiropractic or Alvin Health, for x-rays is for the examination and interpretation of the X-ray negatives and will remain the property of the clinic, being on file where they can be seen at any time while patient at this office.

As the patient, or on behalf of the patient (in case of a minor or other individual), I agree that I am responsible for any bills incurred at HealthWorks Chiropractic or Alvin Health.

Assignment & Release

In considering the medical expenses to be incurred, I the undersigned, have insurance and/or employee health care benefits coverage and hereby directly assign to HealthWorks Chiropractic of Alvin, PLLC ("HealthWorks") or Family Nurse Practitioners of Alvin, LLC (“Alvin Health”) all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for any services rendered in conjunction with these expenses.

I authorize HealthWorks and Alvin Health to release any personal and medical information to any plan administrator or fiduciary, insurer or attorney as necessary to apply for and/or process reimbursement of my medical expenses incurred at HealthWorks or Alvin Health.

I authorize any plan administrator or fiduciary, insurer and my attorney to release to HealthWorks or Alvin Health any plan documents, insurance policy and/or settlement information as necessary to apply for, understand and/or process reimbursement of my medical expenses incurred at HealthWorks or Alvin Health.

I understand that I am and remain financially responsible for all charges regardless of any applicable insurance or benefit payments.

If so requested, I agree to cooperate with HealthWorks and Alvin Health in any attempts by HealthWorks or Alvin Health to secure reimbursement of medical expenses incurred at HealthWorks or Alvin Health from my plan administrator or fiduciary, insurer or attorney.

This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I have read and fully understand this agreement.

 

Signature

In agreement of the above policies, disclosures and statements, I hereby apply my signature below.

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Our Financial policy

At HealthWorks and Alvin Health, we are dedicated to providing the best possible care for you, and we want you to completely understand our financial policies to avoid any future misunderstandings.

Treatment Plan- It is very important to follow the schedule outlined in the prescribed treatment plan. Missed appointments and treatment gaps slow the healing process and may increase the number of treatments required. In this case, you will be responsible for the cost of the extra appointments beyond those outlined in the prescribed treatment plan.

Insurance Benefits- Benefit estimates given by your insurance company are no guarantee of payment, and your portion may be different from what we were told when we verified coverage. In this case, we will either refund you the excess or invoice you the difference.

Insurance Co-Pay & Deductibles- When your insurance company specifies a co-pay or deductible; this payment is due at the time of service unless arranged otherwise with us.

Insurance Filings- As a service to you, we will file your insurance claim, if you assign the benefits to us so that your insurance company can pay us directly. We will also follow up for you, but if your insurance company does not pay the claim within a reasonable period, you are responsible for payment.

Self-pay- If you do not have insurance, or if we cannot verify your coverage, payment is due at time of service unless arranged otherwise with us.

Returned Checks- We will charge a fee of $25 for all checks returned unpaid.

Collections - if your account is ever assigned to an attorney or outside agency for collections or litigation, HealthWorks and/or Alvin Health shall be entitled to reasonable attorney's fees and the cost of collections.

Missed Appointments- As a way to honor everyone's schedule, we reserve the right to charge a $25 fee for appointments missed without a one day advance notice.

Credit Payments- We gladly accept Visa and MasterCard, and offer CareCredit for treatment financing. Other credit arrangements may be possible, please ask if these are of interest.

Refunds- We will normally make full refund of any unapplied funds within .30 days of cancellation in case of an unfinished prepaid treatment program. The credit balance is calculated as the amounts paid, less the list price of any treatments received to date.

Your Agreement- I have read and understand the practice's financial policy. I agree to be bonded by its terms as indicated by my signature below. I authorize the release of any information necessary to determine liability for payment and reimbursement for any claim.

 

Signature

In agreement of the above Financial Policy and statements, I hereby apply my signature below.

90% complete

Consent to Use and Disclosure of Protected Health Information (PHI)

Your PHI will be used by HealthWorks Chiropractic and/or Alvin Health and may be disclosed to others for the purposes of treatment, obtaining payment or supporting the day-to-day operations of this office.

You should review the Notice of Privacy Practices for a more complete description of how your PHI may be used or disclosed. It describes your rights as they concern the, limited use of health information, including your demographic information, collected from you and created or received by this office.

You may review the Notice prior to signing this consent. You may request a copy of the Notice at the Front Desk. You may request a restriction on the use of disclosure of your PHI, however, we may or may not agree to restrict the use or disclosure of your PHI.

If we agree to your request, the restriction will be binding with this office. Use or disclosure of Protected information in violation of an agreed upon restriction will be violation of the federal privacy standards.

You may revoke this consent to the use and disclosure of your PHI. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected.

Please note that HealthWorks and Alvin Health reserve the right to modify the privacy practices outlined in the Notice.

Authorization for Use and Disclosure of PHI

The Information to Be Used or Disclosed covered by this authorization includes:

· We may use your email to notify you of announcements, health tips and appointment reminders

· We may use your cellphone number to send you text messages for your appointments and events

· We may use your home address to send you a yearly birthday card 

Persons authorized to Use or Disclose Information

Information will be used or disclosed by the staff, contractors and agents of HealthWorks Chiropractic or Alvin Health.

Expiration Date of Authorization / Right to Terminate

This authorization is effective for a five-year period that renews automatically unless revoked or terminated by patient or patient’s personal representative in writing.

Potential for Re-Disclosure

Information that is disclosed under this authorization may be disclosed again by the person or organization to which it is sent. The privacy of this information may not be protected under the federal privacy regulations.  The use or disclosure requested under this authorization will not result in direct or indirect remuneration to this office.

 

Signature

I have read and understand the policies as noted above.   I have read the above and hereby agree & authorize the release & use of my PHI as described above.  

95% complete

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Certification of Accuracy

I hereby certify that the information provided in this Patient Information package to HealthWorks Chiropractic and/or Alvin Health is true and correct to the best of my knowledge. I understand that making false statements in this Patient Information package may disqualify me from insurance or other benefits, and may also be in violation of state and federal law.

 

Signature

In certification of the accuracy of all information provided in this form, I hereby apply my signature below.

99% complete

FINISHED!!!

Lastly, enter your name below and press the "Submit Form" button below to send your medical history to HealthWorks.   You will an email conformation of your submission.

 

In case of any questions, please contact our office at (281) 585-3500.

Thank you for your submission - we hope to see you soon!