Healthcare Chiropractic Corporation Form

HEALTHCARE CHIROPRACTIC CORPORATION FORM

Patient Information

Date of Birth:    Gender: Male Female Other Prefer not to say

Emergency Contact

Insurance Information

Subscriber Date of Birth:    Subscriber Relation:

Medical History

Primary reason for visit:

Date symptoms began:    Pain severity (0-10):

Are you currently pregnant? Yes No

Do you have a pacemaker or implanted device? Yes No

Consent for Chiropractic Evaluation and Treatment

I, , hereby authorize Healthcare Chiropractic Corporation and its clinicians to perform chiropractic evaluation, spinal manipulation, therapeutic modalities, rehabilitative exercises, and related procedures as deemed necessary by the treating clinician.

Description of proposed treatment:

Risks: I understand that, as with any manual therapy or medical intervention, risks exist including but not limited to temporary soreness, soft tissue injury, aggravation of pre-existing conditions, and rare complications. The treating clinician has explained potential risks and alternatives and I have had the opportunity to ask questions.

Benefits and Alternatives: The anticipated benefits include reduction of pain, improved mobility and function. Alternatives may include no treatment, referral for imaging, medication, physical therapy, or surgical consultation.

I acknowledge that I may withdraw consent at any time, except where withdrawal would cause harm from an in-progress procedure. Withdrawal of consent will be provided in writing to the clinic.

Consent options: I consent to evaluation and treatment I consent to emergency treatment if necessary

Financial Responsibility & Assignment of Benefits

I understand that I am financially responsible for charges not covered by my insurance carrier, including co-payments, deductibles, co-insurance, and non-covered services. I authorize payment of insurance benefits to Healthcare Chiropractic Corporation for services rendered on my behalf.

Assignment of benefits: I assign and authorize direct payment to Healthcare Chiropractic Corporation of any insurance or third-party benefits payable for services. I authorize release of medical information necessary to process claims.

Insurance billing consent: I authorize the clinic to bill my insurance. I accept financial responsibility.

HIPAA Authorization and Privacy Acknowledgment

I acknowledge receipt of the clinic's Notice of Privacy Practices. I authorize Healthcare Chiropractic Corporation to use and disclose my protected health information for treatment, payment, and healthcare operations as described in that notice.

Authorization to discuss my protected health information with the following persons (if any):

This authorization will remain in effect until: or until revoked in writing.

I acknowledge that I have received and reviewed the Notice of Privacy Practices and authorize the uses and disclosures described above.

Release of Records and Authorization to Share

I authorize Healthcare Chiropractic Corporation to release my medical records related to treatment to:

Authorization expiration date:

Patient Certification

I certify that the information I have provided on this form is true and complete to the best of my knowledge. I understand that withholding information or providing false information may be detrimental to my treatment and may affect billing. I consent to treatment and authorize release of information and assignment of benefits as indicated above.

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