Patient Health Information Consent Form

Transcription

1 Patient Health Information Consent Form We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we will begin any health care operations we must require you to read and sign this consent form stating that you understand and agree with how your records will be used. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent. 1. The patient understands and agrees to allow this chiropractic office to use their Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operations, and coordination of care. As an example, the patient agrees to allow this chiropractic office to submit requested PHI to the Health Insurance Company (or companies) provided to us by the patient for the purpose of payment. Be assured that this office will limit the release of all PHI to the minimum needed for what the insurance companies require for payment. 2. The patient has the right to examine and obtain a copy of his or her own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI. Our office is not obligated to agree to those restrictions. 3. A patient's written consent need only be obtained one time for all subsequent care given the patient in this office. 4. The patient may provide a written request to revoke consent at any time during care. This would not effect the use of those records for the care given prior to the written request to revoke consent but would apply to any care given after the request has been presented. 5. For your security and right to privacy, all staff has been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures in our office. We have taken all precautions that are known by this office to assure that your records are not readily available to those who do not need them. 6. Patients have the right to file a formal complaint with our privacy official about any possible violations of these policies and procedures. 7. If the patient refuses to sign this consent for the purpose of treatment, payment and health care operations, our office has the right to refuse to give care. I have read and understand how my Patient Health Information will be used and I agree to these policies and procedures. Name of Patient (please print) Signature of Patient/Guardian Date DR. NINA GILBERT, D.C ST. FRANCIS DRIVE SANTA FE,NM OFFICE: 505/ FAX:

2 DR. NINA GILBERT, D.C So. St. Francis Dr., Santa Fe, NM (O) (F) Patient Financial Agreement OFFICE HOURS: Tuesday, Thursday and Friday by Appointment Only. If you have an emergency, please call and I will do my best to see you that day. If I am out of town, there are many other chiropractors in town or go to the emergency room at the hospital. If you must cancel an appointment, please give 24 hours notice so that I may give another patient the opportunity for care. Notice of less than 24 hours will result in a charge. Payment is expected at the time service is rendered. A service charge will be applied to all balances over 30 days. This is calculated at a monthly percentage rate of 1.5% (armual rate of 18%). Those with insurance are reminded that they are responsible for the interest that occurs as a result of slow remittance by their insurance company. Payment of any and all charges not covered by insurance is your responsibility and payment will be expected when such charges are recognized. Dr. Gilbert may consider other payment arrangements as needed on an individual basis. I have read and understand the above paragraphs. In addition, I understand that I am financially responsible to Dr. Gilbert, if services recommended and received are not covered under my health plan, if my eligibility is not confirmed prior to treatment, if charges exceed my plan's maximum benefit, if my employment status has been altered, if my insurance has been terminated, if I choose to receive treatment on my own without a prior authorization or referral, if I choose to receive treatment beyond what my health plan authorizes or for any non-covered services I accept and receive. Signature Date

3 Informed Consent for Chiropractic Treatment TO THE PATIENT: You have a right to be informed about your conditior\, the recommended chiropractic treatment, and the potential risks Involved with the recommended treatment. This information will assist you in making an informed decision whether or not to have the treatment. This information is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give or refuse to give your consent to treatment. I request and consent to chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic X-rays. The chiropractic treatment may be performed by the Doctor of Chiropractic named below and/or other licensed Doctors of Chiropractic working at this clinic or office. Chiropractic treatment may also be performed by a Doctor of Chiropractic who is serving as a backup for the Doctor of Chiropractic named below I have had the opportunity to discuss with the Doctor of Chiropractic named below, my diagnosis, the nature and purpose of my chiropractic treatment, the risks and benefits of my chiropractic treatment, alternatives to my chiropractic treatment, and the risks and benefits of alternative treatment, including no treatment at all. I understand that, there are some risks to chiropractic treatment including, but not limited to: Broken bones increased symptoms and pain Dislocations No improvement of symptoms or pain Sprains/strains Infection (acupuncture) Burns or frostbite (physical therapy) Punctured lung (acupuncture) D Worsening/aggravation of spinal conditions D Other In rare cases there have been reported complications of vertebral artery dissection (stroke) when a patient receives a cervical adjustment. The complications reported can include temporary minor dizziness, nausea, paralysis, vision loss, locked in syndrome (complete paralysis of voluntary muscles in all parts of the body except for those that control eye movement), and death. I do not expect the doctor to be able to anticipate and explain all risks and complications. I also understand that no guarantees or promises have been made to me concerning the results expected from the treatment. TREATMENT PLAN: I have read, or have had read to me, the above consent. I have also had aa opportunity to ask questions. All of my questions have been answered to my satisfaction. By signing below, I consent to the treatment plan. I intend this consent form to cover the entire course of treatment for my current condition. To be completed by the patient: To be completed by the patient's representative: print name print name of patient signature of patient print name of patient's representative date signed signature of patient's representative as: relationship/authority of patient's representative date signed To be completed by doctor or staff: witness to patient's signature date translated by date

4 Patient History Mame. Date Addi-ess _^ Stale Zip H. Phone ( ) W. Phone Dale of Birth Age_ Referred by Social Security # Occupation ' Employer Marital Status S M D W Spouse Name ^ Number of Children/Ages_ ^ _. 4?^^^// /4Vo/r(?JKJ Have you ever received Chiropractic Care? Yes No Please circle for each of the following: 1. Regarding your Birth Process: Was the delivery long/difficult? _ Forceps or extraction used? _ Cesarean/C-Section? Breach/ cephalic? _ Home birlh? _ Hospital birth? _ Mother given drugs during delivery? _ Was labor induced? _ 2. Growth and Development/ Childhood: Were you breast fed? _ Health education? Childhood illnesses? YN_ Ear infections/ Colic/ Asthma? _ Attention Deficit? _ Antibiotics? Drugs, prescription, OTC, recreational? _ Surgep/? Hospitalizations? Sports or other physical activities Injuries during sports? Auto accidents? _ Did you have other traumas? Did you ever break any bones? _ 3. Current Health Habits: Did/do you smoke? Did/do you drink alcohol?. Diet, do you eat healthy foods? Have you been in accidents/trauma? Have you had surgery? Drugs, prescription, OTC, recreational? Dental problems? Eye problems? Hearing problems? YN Exercise regularly? Did/do you have occupational stress? Drive? Daily time spent driving Physical stress? Emotional/Menial stress? Hobbies/Sports injuries? Do you sleep well, hours of sleep? Sleeping posture? O side O stomach O back Patient Comment If answer is Yes Chiropractor's Comments Symptoms and Present State of Health Present Complaint/Reason for Seeking Caie in this Office: M a i o r Pain or Problem started on Pains are: O Sharp O Dull/ Ache O Constant O Intermittent O Other Does this pain shoot, radiate, or travel in your body? Where? Are you experiencing numbness or tingling in any area of your body? Where? Since it began, is it: O Same O Better O Worst What activities aggravate your condition/pain? What activities lessen your condition/pain?

5 Is this condition worse during certain times le day? Is this condition interfering with Work? Sleep? Routine? Other? Is this condition progressively getting worse? Other Doctors seen for this condition Any home remedies? Please Circle where you are at: (No Complaint/Pain) (Worst Possible Complaint/Pain) Using the symbols below, mark on the pictures where you feel pain. Numbness = = = Dull Ache OOO Burning XXX Sharp/Stabbing /// Pins, Needles Other '-^'^ Please mark any of the following conditions or symptoms that you have now or have experienced: Other Symptoms: 0 Headaches 0 Pain in Hands or Arms 0 Chest Pains 0 Neck Pain 0 Numbness in Hands or Arms O Heart Attack O Sleeping Problems O Pain in Legs or Feet 0 High Blood Pressure O Low Back Pain O Numbness in Legs or Feet O Stroke 0 Nervousness 0 Fatigue O Cancer 0 Tension 0 Depression 0 Painful Urination O Irritability O Lights Bother Eyes O Diabetes 0 Dizziness 0 Loss of Memory O Diarrhea 0 Pain Between Shoulders 0 Shoulder Pain 0 Constipation ONeck Stiff O Sinus O Stomach Upset O Joint Swelling 0 Shortness of Breath 0 Heartburn/Reflux O Fever 0 Asthma 0 Weight Loss O Loss of Balance 0 Allergies 0 Loss of Smell or Taste O Ringing in Ears 0 Cold Hands 0 Menstrual Cramps O Jaw/TMJ Problems O Cold Feet 0 Menopause Are you under medical care for any condition? What Medications are you taking? How long? Have you had surgery? What? When? What side effects have you experienced from the drugs and surgery? Females Only - Date last Menstrual Period began on Are you possibly Pregnant? Is there a family Histoi-y of: Heart Disease Arthritis Cancer Diabetes Other Father's side O O O O O Mother's side O O O O O 1 hereby certify that the statements and answers given on this form are accurate to the best of knowledge and understand it is my responsibility to inform this office of any changes in my health. ] agree to allow this office to examine me for further evaluation. Patient Signature Date