PS CHIROPRACTIC PATIENT CASE HISTORY Personal Information Last Name First Name Middle Initial Address: City: State: Zip: Home Phone: - - Work Phone: - - Cell Phone: - - Date of Birth: age Social Security #: - - Gender: Email Address: Occupation: Employer/School Phone: - - Spouse's Name D.O.B. SSN - - Spouse's Employer Phone: - - In case of emergency, contact Relationship Home Phone: - - Work Phone: - - Insurance Information Who is responsible for this account? Relationship to Patient Insurance Company Group # ID # Is Patient covered by additional insurance? Subscriber's Name D.O.B. SSN - - Relationship to Patient Insurance Company Group # Assignment and Release I certify that I, and/or my dependent(s), have insurance coverage with (insurance co) and assign directly to Drs. Ben and/or Pam Avritt all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above named doctors may use my health care information and may disclose such information to the above-named insurance company and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below. Signature Date Print Name Date Relationship to Patient
Patient Condition PLEASE MARK YOUR AREAS OF PAIN ON THE DIAGRAM BELOW (mark ALL areas with XXXXXXX) Main reason for consulting our office: Become pain free Explanation of my condition Learn how to care for my condition Reduce symptoms Resume normal activity level What is your MAJOR complaint? Date problem began? How did this problem begin (falling, lifting, etc.)? How is your condition changing? NOT CHANGING Have you had this condition in the past? YES - NO How often do you experience your symptoms? Constantly (76- -75% of the day) Occasionally (26-50% of the day) Intermittently (0-25% of the day) Describe the nature of your symptoms: Sharp Dull Numb Burning Shooting Tingling Radiating Pain Tightness Stabbing Throbbing Other: Please rate your pain on a scale of 1 to 10 (0= no pain and 10= excruciating pain) 1 2 3 4 5 6 7 8 9 10 How do your symptoms affect your ability to perform daily activities such as working or driving? (0= no effect and 10= no possible activities) 1 2 3 4 5 6 7 8 9 10 What activities aggravate your condition (working, exercise, etc)? What makes your pain better (ice, heat, massage, etc)? Are there any other Health Concerns that you would like to talk to us about? - How long ago? Whom may we thank for referring you? How did you find out about us?
Allergies - Surgeries Past Medical History -Back Pain Medications Do you take Vitamins/Supplements Family History Have you had any auto or other accidents? Describe: Have you ever cracked or broken a rib? - when? how? Do you have pain when you cough, sneeze, or bear down to go to the bathroom? Date of last physical examination: Do you drink c - how many per day? - how many per day?
DISCLOSURE & CONSENT CHIROPRACTIC ADJUSTMENTS AND CARE TO THE PATIENT: You have a right as a patient to be informed about your condition and recommended chiropractic adjustments and other chiropractic procedures to be used so that you may make the decision whether or not to undergo the procedure after knowing the potential risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give or withhold your consent to the procedure I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic x-rays, on me (or the patient named below, whom I am legally responsible) by the Doctor of chiropractic named below and or other licensed doctors of chiropractic or those working at the clinic or office who now or in the future treat me while employed by, working or associated with, or serving as a backup for the doctor chiropractic named below. I have had the opportunity to discuss with the doctor of chiropractic named below, my diagnosis, the nature and purpose of chiropractic adjustments and other procedures and alternatives. I understand and I am informed that in the practice of chiropractic there are some risks to exam and treatment including, but not limited to, fractures, disc injuries, strokes, dislocations, sprains and increased symptoms and pain or no improvement of symptoms or pain. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based on the facts then known, is in my best interest. I further acknowledge that no guarantees or assurances have been made to me concerning the results intended from the treatment. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions and all my questions have been answered fully and satisfactorily. By signing below, I consent to the treatment plan. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. To be completed by the patient: Print name: Signature of patient/representative Date signed: Member of Doctors staff: Date signed
PATIENT RECORD OF DISCLOSURES In general, the HIPPA Privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI is made by alternative means, such as sending correspondence to the individual s office instead of individual s home. I wish to be contacted in the following manner (check all that apply) Home phone Leave message with detailed information home Leave message with call-back # ONLY at home Work telephone Leave message with detailed info at work Leave message with call-back # ONLY at work Written communication Mail to my home address Mail to my work/ office address below Fax information to Leave message with detailed information at home Other Patient Signature: Date: Below this line for office use only! The Privacy Rule generally requires healthcare providers to take reasonable steps to limit the use of disclosure of, and requests for PHI to the minimum necessary to accomplish the intended purpose. These provisions do not apply to uses or disclosures made pursuant to an authorization requested by the individual. Healthcare entities must keep records of PHI disclosures. Information provided below, if completed properly, will constitute an adequate record. NOTE: Uses and disclosures for TPO may be permitted with prior consent in an emergency. Date Disclosed to whom/address of fax number (1) Description of disclosure/purpose of disclosure By Whom Disclosed (2) (3) (1) Check this box if the disclosure is authorized (2) Type Key: T-Treatment Records: P-Payment Information: O-Healthcare Operations (3) Enter how disclosure was made F-Fax: P-Phone: M-Mail: O-Other
MEDICARE FINACIAL POLICY Medicare covers Chiropractic manipulation only. These services are covered after you have met your deductible every year. Manipulations are usually limited to 12 to 24 visits per 12-month period. The number is dependent on Medicare s decision of Medical Necessity. Examination and x-rays are NOT covered by Medicare and are not applied to your deductible; therefore we ask that you pay for these services on your first visit. X-rays must be available for Medicare Review. If you have additional Health Insurance they usually do not cover any services not approved by Medicare. They may or may not pay for chiropractic manipulations. We do not file secondary insurance but will show you how to do so yourself if Medicare does not roll it over. We will do all that we can to help get your claims paid. Please understand that we do not make the rules, but we do abide by them. By signing this document, I am taking full responsibility for paymentof the services I receive at PS Chiropractic, Inc. Furthermore, I agree that if I do not abide by the financial policies stated above, my account will be turned over to your collections agency with a 45% collection fee to be collected at my expense. Everything that I have stated in my Chiropractic Registration and History Form is correct. I understand that you will retain this Chiropractic Registration and History Form in my file. Patient Signature: Date: Employee Witness: If you have any questions regarding our policies, please let us know. We want to assist you in any way that we can!
PATIENT HISTORY PAIN LOCATION Please mark off the areas of your complaint on the diagram above. Please use the following symbols on the pain diagram to accurately describe your condition. PPP Where you experience Pain NNN Where you experience Numbness TTT Where you experience Tingling BBB Where you experience Burning CCC Where you experience Cramping PATIENT SIGNATURE DATE
X-RAY CONSENT I (patient s name), give consent to take the following x-ray views: deemed necessary from my case history and examination. By signing this document, I am taking full responsibility for payment of the services not paid by insurance, including x-rays I receive at PS Chiropractic, Inc. Patient Signature: Date: Employee Witness: ------FEMALES: Please continue with the section below------ *The last days following onset of menstrual cycle are generally considered safe for x-ray examinations* Onset of last menstrual cycle date: Today s Date: (Please Check) YES NO I am pregnant I have had a hysterectomy I use an IUD I recognize that if I am pregnant and have radiation to my abdomen, there is a possibility of injury to the fetus. Therefore, if you think there is a chance that you may be pregnant, then it is up to you to inform PS Chiropractic. Therefore, by signing this document, you are giving PS Chiropractic permission to perform the above x-ray examinations. Patient Signature: Date: Employee Witness: 430 Hampton Ave Pickens SC 864-878-8190 www.pschiro.com
Quadruple Visual Analogue Scale Patient Name Date PLEASE READ CAREFULLY: INSTRUCTIONS: Please circle the number that best describes the question asked. NOTE: If you have more than one complaint, please answer each question for each individual complaint and indicate the score for each complaint. Please indicate your pain level right now, average pain, and pain at its best and worst. Example: Headache Neck Low Back worst possible No pain pain 0 1 2 3 4 5 6 7 8 9 10. 1-What is your pain RIGHT NOW? worst possible No pain pain 0 1 2 3 4 5 6 7 8 9 10 2-What is your TYPICAL or AVERAGE pain? worst possible No pain pain 0 1 2 3 4 5 6 7 8 9 10 3-What is your pain level AT IITS BEST (How close to 0 does your pain get at its best)? worst possible No pain pain 0 1 2 3 4 5 6 7 8 9 10 4-What is your pain level AT ITS WORST (How close to 10 does your pain get at its worst)? worst possible No pain pain 0 1 2 3 4 5 6 7 8 9 10 OTHER COMMENTS: 430 Hampton Ave Pickens SC 864-878-8190 www.pschiro.com
CONSENT FOR USE OR DISCLOSURE OF HEALTH INFORMATION Privacy Pledge To You: We are very concerned with protecting your privacy. While the Law requires us to give you this disclosure, please understand that we have, and always will, respect the privacy of your health information. There are several circumstances where we may have to use or disclose your health information: We may have to disclose information to another health care provider or hospital if it is necessary to refer you to them for the diagnosis, assessment or treatment of your health. We may have to disclose information and billing records to another party if they are potentially responsible for the payment of your services. We may have to use your health information within our practice for quality control or other operational purposes. We have a more complete notice that provides a detailed description of how your health information may be used or disclosed. You have a right to review that notice before you sign this consent form (164.520). We reserve the right to change our privacy practice as described in that notice. If any changes are made, you will be notified in writing by our office. Please feel free to call us at any time for a copy of our privacy notices. Your Right to Limit Uses Or Disclosures: You have a right to request that we do not disclose your health information to specific individuals, companies or organizations. If you would like to place restrictions of the use or disclosure of your health information, please do so in writing. We are not required to agree to your restrictions. However, if we agree with your restrictions, the restriction is binding to us. Your Right to Revoke Authorization: You may revoke your consent to us at any time; but it must be done in writing. We will not be able to honor your revocation request if we have already released your health information prior to receiving your request to revoke authorization. If you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they decide to contest any of your claims. APPOINTMENTREMINDER AND HEALTH CARE INFORMATION AUTHORIZATION Your Chiropractor and members of our staff at PS Chiropractic need to use your name, address, phone number, and your records to contact you with appointment reminders, information about treatment alternatives, or other health related information that may interest you. If this contact is made by phone and you are not home, a message will be left on your answering machine. By signing this form, you are giving us authorization to contact you with these reminders and information. You may restrict the individuals or organizations to which your health information is released to or you may revoke your authorization to us at any time. However, your revocation must be done in writing and mailed to our office address. We will not be able to honor any revocation request if we have already released your health information prior to our office receiving your request to revoke authorization. In addition, if you were required to give your authorization as a condition of obtaining insurance, the insurance company may have the right to your health information if they decide to detest a claim. Information we use or disclose based on the authorization you re giving may be subject to re-disclosure by anyone who has access to the reminder or other information and may no longer be protected by the federal privacy rules. You have the right to refuse to give us this authorization. If you do not give us this authorization, it will not affect the treatment we provide to you or the method we use to obtain reimbursement for your care. You may inspect or copy the information we use to contact you to provide appointment reminders, information about treatment alternatives or other health related information at any time. (164.524) I have read your consent policy and agree to its terms. I am also acknowledging that I have received or been offered a copy of this notice. This notice is effective as of the date listed below. This authorization will expire seven years after the date of which you last receive services from us. I authorize you to use or disclose my health information in the manner described above. Patient Name Printed: Date: Patient Signature: Employee Witness: *(Or Personal Representative-also please describe how personal representative acts as authority for patient) 430 Hampton Ave Pickens SC 864-878-8190 www.pschiro.com
B. Patient Name: C. Identification Number: Advance Beneficiary Notice of Noncoverage (ABN) NOTE: If Medicare doesn t pay for D. below, you may have to pay. Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the D. D. E. Reason Medicare May Not Pay: F. Estimated Cost Spinal Adjustments Not Medically Necessary 98940, 98941, Exams, Therapies, X-rays Excluded by Contract 98942 List Additional Supplies/Services Excluded by Contract List below. WHAT YOU NEED TO DO NOW: Read this notice, so you can make an informed decision about your care. Ask us any questions that you may have after you finish reading. Choose an option below about whether to receive the D. listed above. Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this. G. OPTIONS: Check only one box. We cannot choose a box for you. OPTION 1. I want the D. listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles. OPTION 2. I want the D. responsible for payment. I cannot appeal if Medicare is not billed. OPTION 3. I don t want the D. payment, and I cannot appeal to see if Medicare would pay. H. Additional Information: listed above, but do not bill Medicare. You may ask to be paid now as I am listed above. I understand with this choice I am not responsible for This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048). Signing below means that you have received and understand this notice. You also receive a copy. I. Signature: J. Date: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850. Form CMS-R-131 (03/11) Form Approved OMB No. 0938-0566 430 Hampton Ave Pickens SC 864-878-8190 www.pschiro.com