WELCOME TO OUR OFFICE!
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- Marilynn Garrison
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1 WELCOME TO OUR OFFICE! Name Date: / / Address City State Zip Home Phone Cell Phone Birthdate Age SS# Race: Marital Status: M W D S Employer Work Phone Occupation Name & Birthdate of Primary Insured Spouse Name Primary Care Medical Doctor Name & Location Most patients are referred to our office by a caring family member or friend. What brought you in contact with our office? Friend/Family Member/Doctor Name Postcard Sign Internet Billboard Newspaper Name Event Seminar Please describe the primary health complaint you are experiencing. How long have you had this condition? Doctor treating condition: Treatment Received: Other Doctor: Other Treatment: Please list all surgeries What medications are you currently taking and for what conditions? Is this condition related to an automobile accident or injury suffered at your job? Yes No Are you or could you be pregnant? Yes No Please put an X next to any current conditions and a P next to any past conditions: Hip Pain R / L Digestive Problems Headaches Cancer Asthma Foot Trouble R / L High/Low Blood Pressure Ear Infection Tremors Stroke Shoulder Pain R / L Sinus Problems Allergies Arthritis Irritable Convulsions/Epilepsy Trouble Sleeping Fractured Bones Fainting Depression Trouble Concentrating Accidents/Falls Loss of Balance Anemia Heartburn Jaw Pain/TMJ R / L Pain w/ Cough/Sneeze Skin Problems Dizziness Ulcers Ringing in Ears R / L Difficulty Breathing Heart Problems Chest Pain Diabetes Help our Therapists help you! Circle your preference below. The above information is true and accurate to the best of my knowledge. Tobacco Use? Yes No Light amount of pressure Moderate amount of pressure Heavy amount of pressure Patient Signature Date
2 To Our Patients Regarding Cancellations and No-Shows The following are our policies regarding cancellations and no-shows. We take this subject seriously because it can make a difference between responding to treatment or not. Usually your referring doctor and/or therapist have prescribed a set frequency of treatment. If you show up for treatment, it will enable you to get better. Other than that all you need to do is follow your doctor s instructions, and you should achieve your treatment goals. We require 24 hours notice in the event of a cancellation. It is your responsibility, when you call in, to have an alternative time in mind that will ensure you get the full number of prescribed treatments that week whenever possible. There is a $20 charge for a cancellation or no-show without proper notice. This charge will not be covered by you insurance, but will have to be paid by you personally. For Workmen s Compensation and Personal Injury patients, documentation of any missed appointments is forwarded to your case manager and primary physician. This could jeopardize your claim. You may occasionally need to see another physician other than the one who normally sees you if you do need to re-arrange your appointment. All of our physicians are experienced professional and they will study your chart. You may return to your original physician at the next appointment. Please understand that your pain will probably increase and decreases as your course of treatment progresses and before it is finally eliminated. Either condition should not be a reason not to come in: 1) Your pain is gone or 2) Your pain is worse. If the pain is gone, now is the time to really begin rehabilitating the injured area to prevent recurrence. If your pain is worse, we can do something to help. When you don t show as scheduled, three people are hurt. 1) You, because you didn t get the treatment you need as prescribed by your doctor; 2) The doctor who now has a hole in their schedule; 3) The person that couldn t get in when you had your appointment scheduled. Thank you for cooperating with us on this matter. We are looking forward to working with you. Patient Signature Date
3 ABBREVIATED NOTICE OF PRIVACY POLICY FOR JACKSONVILLE SPORT & SPINE Effective October 1, 2005 We collect your personal health information from you through treatment, payment or other means as applicable. Your personal health information is protected by federal law. Generally we do not use or disclose your information without your permission. Once permission has been obtained, we must disclose your personal health information in accordance with the specific terms of permission. The following is an outline of the circumstances under which we are permitted by law to use or disclose your personal health information. You may request a copy of the detailed privacy policy with a written request sent to: JACKSONVILLE SPORT & SPINE 2233 PARK AVE. STE. 200B ORANGE PARK, FL Without your consent we may use or disclose your personal health information in order to provide you with services and treatments you may require or request, or to collect payment for services and/or to conduct other operations otherwise permitted or required by law. We can also disclose your personal health information within and among our workforce to accomplish the same purposes. 2. As required by law we may use or disclose your personal health information to the extent that such use or disclosure as required by law and the use or disclosure complies with and is limited to the relevant requirements of such law. 3. All other situations with your specific authorization. Except as otherwise permitted or required, as outlined above, we may not use or disclose your personal health information without your written permission. You may revoke your authorization at any time except in some circumstances. 4. Miscellaneous activities NOTICE: We may contact you to provide appointment reminders or information about treatments or other health-related benefits and services that may be of interest to you. YOUR RIGHTS WITH RESPECT TO YOUR PERSONAL HEALTH INFORMATION 1. Right to request restrictions on use or disclosure 2. Right to receive confidential information 3. Right to receive confidential communications 4. Right to inspect and copy your personal health information 5. Right to amend your personal health information 6. Right to receive accounting of disclosures of your personal health information 7. Right to file a complaint with us and the Secretary of the DHHS if you believe your privacy rights have been violated. You may submit your complaint in writing by mail to our privacy officer, JACKSONVILLE SPORT & SPINE, within 180 days of when you knew or should have known the act of omission complained of occurred. You will not be retaliated against for filing any complaint. We reserve the right to amend this privacy policy at any time for which we will provide you with notice within 60 days of the effective date of such revision, amendment or change.
4 PRIVACY PRACTICES ACKNOWLEDGMENT I. ACKNOWLEDGMENT OF PRIVACY PRACTICE NOTICE I have received/reviewed a copy of JACKSONVILLE SPORT & SPINE S Notice of Privacy Practices: Patient s Name Date of Birth Signature of Patient/Parent Date II. Open Adjusting Rooms: Due to the open office floor plan, sensitive matters should be discussed in private. Please make the doctor aware of any such issues so appropriate arrangements can be made for privacy. III. DESIGNATION OF RELATIVES, FRIENDS AND OTHER CAREGIVERS FOR HEALTHCARE DISCLOSURE I agree that JACKSONVILLE SPORT & SPINE may disclose certain healthcare information to persons involved with my healthcare decisions or payment. I designate the following person(s) listed below as being involved with my healthcare for the purpose of JACKSONVILLE SPORT & SPINE making limited information disclo-sure for the above purpose. I UNDERSTAND I AM NOT REQUIRED TO LIST ANYONE. I also understand I may change the designees in writing at any time. Print Name Relationship Contact Phone # INFORMED CONSENT I hereby request and consent to the performance of: physical examination and any other diagnostic tests such as x-rays to diagnose my condition(s), and of spinal adjustments, extremity adjustments, physical therapy, and axial decompression. If during the course of care the doctors encounter non-chiropractic or unusual findings, they may recommend I consult a specialist for the area in question. I have had the opportunity to discuss with the doctor or office personnel that results are not guaranteed and the rare risks of treatment. I do not expect the doctors to be able to anticipate and explain all risks and complications, and wish to rely upon the doctor s judgment during the course of treatment, based upon the facts then known, that is in my best interest. This consent will cover the entire course of my treatment for present conditions or any future conditions for which I seek treatment. I have read and understand the terms above and grant permission for care: Patient s Signature Date In case of emergency, contact Phone # Complete if patient under 18 years of age: Child Name: As parent/legal guardian of above child, I understand the terms above and grant permission for treatment. Parent/Guardian Signature Date
5 ASSIGNMENT OF BENEFITS Patient Name Address City State Zip Insurance Company Name of Policyholder Policy Number 1. I, the undersigned, hereafter referred to as the patient do hereby assign all of my rights and interests to JACKSONVILLE SPORT & SPINE, hereafter referred to as "the medical provider" to pursue and obtain payment from the above mentioned insurance carrier. 2. I, irrevocably assign, to the medical provider, all my rights and benefits under the insurance contract for payment for services rendered to me. 3. I, the patient, do hereby understand and acknowledge that if I willfully refuse to comply with reasonable requests of the insurance carrier, payment of my medical bills may be denied and I will be held responsible for same. 4. I, the patient, do hereby direct my health insurance carrier and/or other insurance carrier to issue payment on my behalf directly to the medical provider. The check should be made payable to the medical provider. Further, in the event that the health carrier and/or other insurance carrier fails to forward the check to the medical provider, I will endorse and sign the check to the medical provider within (5) days of receipt of same. 5. For any/all balances over 120 days, a collection fee of $20.00 will be added to your balance. Signed Patient s Name Dated Witness
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Practice Limited to Infants, Children, & Adolescents
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MR #: Patient Name: Page: 1 of 4 PROGRESSIVE PHYSICAL THERAPY PATIENT DATA SHEET. May we send you text messages relating to your care with us?
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WORKERS COMPENSATION PATIENT DEMOGRAPHICS Name: Date: Age: Date of Birth: S.S#: Email: Address: Street Name & Number City State Zip Home Phone #: Cellular #: Wk #: Marital Status: S M W D HOW DID YOU HEAR
Person to Contact in Case of Emergency. THE COUNSELING PLACE YOUTH INTAKE FORM Yearly Family Income:
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NPM INTAKE FORM. Home Phone No.: Work Phone No.: Cell Phone:
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CLARK HEARING SOLUTIONS NEW CLIENT REGISTRATION FORM (Please Print Clearly)
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Lipo Laser Weight Loss Action Plan
7921 Tanner Williams Road, Ste B Mobile, AL 36608 Phone 251.607.0040 Fax 251.607.7202 Lipo Laser Weight Loss Action Plan 1. Your first appointment today will consist of a consultation with a doctor. This
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1 Basic Information : Patient s Name: Address: Home Phone: Work Phone: Cell Phone: Email: Age: Birth : Marital Status: Occupation: Educational History: Name, Address and Phone of Child s School Counselor
Patient Registration Form
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Pediatric Patient History
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PATIENT REGISTRATION FORM
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MAIN STREET MEDICAL NEW PATIENT QUESTIONNAIRE
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Adult History Form. Patient Name Today s Date Birth Date Sex Weight Height Name You Go By Please Check Married Single
Adult History Form It is a pleasure to welcome you to our family of happy and healthy chiropractic patients. Please let us know if there is any way we can make you and your family feel more comfortable.
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Address City State Zip Code Home Phone Cell Phone Work Phone Email Address Sex: M F Marital Status: M S D W Date of Birth SS# Spouse Name How did you hear about our office? Employer Name/Occupation Emergency
TOS Health Questionnaire
Name Referring Physician Main Reason for Medical Evaluation of Injury/Length of symptoms: Is this a work related problem? Y N Are you right or left handed? Occupation What treatment have you received for
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