Pecan Valley Chiropractic Center

                                   Personal Information                                                                                


Patient Name: _______________________________________________________  Today’s Date: _________________
                              First            Middle            Last

Address: _________________________________________________________________________________________    
                                                   Street                    Apt#        City            State        Zip

Sex:    M  /   F           Marital Status:    Single    Married    Divorced    Widowed   Separated     Cell: __________________________
DOB: ___________________        SS#: _______ - ______ - ________      Hm: __________________________
Email: www.______________________________________              Wk: __________________________
Employer: ____________________________________         Occupation: _________________________________
Emergency Contact Name/ Relation: ____________________________________ Ph#: _________________________


Patient Type (circle):     Cash    Ins    Auto    Other: ______________

Health Insurance: ____________________________________________    Policy#:________________________
Policy Holder Name: __________________________________________    DOB: ___________________

Secondary Insurance: _________________________________________    Policy#:________________________
Policy Holder Name: __________________________________________    DOB: ___________________

Current Condition
Current Complaint: ________________________________________________________________________________
Is this a work injury?  Y  /  N        DOI: _________________    Accident Report Made w/ Employer:  Y  /   N
Is this an auto accident?   Y   /  N    DOA:_________________    Do you have PIP/ Medpay coverage?  Y   /   N
        
                                    
Referral Source
How were you referred to our office? _________________________________________________________________

(Please note: Anyone who refers someone to our office will receive a special “THANK YOU” gift package!)


I understand and agree that (regardless of my insurance status) I am ultimately responsible for the balance of my account for any professional services rendered.  I have read all the information and have completed the above answers.  I certify this information is true and correct to the best of my knowledge.  I will notify you of any changes in my status on the above information.

________________________________________________            __________________
Patient Signature                                       Date

________________________________________________            __________________
Parent/ Guardian Signature                                   Date




Medications
Please list all medications you are currently taking: _______________________________________________________
_________________________________________________________________________________________________
Please list any vitamins or supplements you are currently taking: ___________________________________________
_________________________________________________________________________________________________

Medical History

Do you smoke?  Y / N  If yes, how much? ____________  Do you chew tobacco Y / N  If yes, how much?__________
Do you drink?  Y / N  If yes, how much? _____________  Do you use recreational drugs?  Y / N
*Are you pregnant or suspect you may be pregnant?  Y  / N   (Please mention to the receptionist & physician during exam)
Circle all that apply to you:

Allergies        Cancer                Hepatitis/ Liver Disease        Stomach Ulcers
Anemia            Coronary Artery Disease    Heart Attack            Stroke
Arthritis        Diabetes            High Blood Pressure        Thyroid Disease
Asthma            Emphysema            High Cholesterol        Tuberculosis (TB)
Bronchitis        Gout                Seizure Disorder        Urinary Tract Infections

If you circled any of the above, please tell us about it: ____________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Please list all surgeries you’ve had & year performed:_____________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________



Neurological

Circle all that apply to you.  And yes, it is really important !
 
Chronic Fatigue            
Constipation or loose stools    
Depressed            
Digestion Trouble or Reflux
Double Vision            
Dry Eyes            
Easy Tearing            
Fast Heartbeat            
Fibromyalgia            
Frequent Urination    
Headache
Hearing Loss
Incontinence
Lose Attention Before Finishing a Task
Sexual Dysfunction
Trouble Swallowing
Unconcerned w/ What’s Happening Around You
Very Compulsive
Very Forgetful
Vision Loss
 

Do you experience any weakness, tingling or numbness? If so, what body part? ________________________________
_________________________________________________________________________________________________




Consent To Treat
I agree to the following:

I, the undersigned, hereby authorize Pecan Valley Chiropractic Center (and whomever may be designated as assistants) to administer such treatments and/ or examinations as they deem necessary.

_______________________________________        _________________            ____________
    Patient Signature                    Date                  Staff Initials


HIPAA Privacy Practices Acknowledgement

I have received the HIPAA Notice of Privacy Practices and/ or I have been provided an opportunity to review it.   I understand that according to the HIPAA Privacy Act, the healthcare provider may disclose any information needed to complete billing and/ or treatment.  Unless listed below, my medical information will be protected.

Name the people and/or organizations that you are authorizing to receive and use your protected health information
(For example: anyone changing or verifying any appointments, questions regarding treatment, etc):

_____________________________________________            _____________________
Printed Name                                    Relation

_____________________________________________            _____________________
Printed Name                                    Relation

_____________________________________________            _____________________
Printed Name                                    Relation

** May we use your name in our newsletters, advertisements, webpage ?       Yes   /    No

_______________________________________        _________________
       Print Patient Name                          Date

_______________________________________        _________________
        Patient Signature                     Staff Initials


Pecan Valley Chiropractic Financial Policy
Basic Policy: Payment is due at the time of service.  I request payment of authorized services be made payable to Pecan Valley Chiropractic Center.
 
Payment Plans:  By choosing one of the available payment options offered during the Report of Findings, I understand that I must adhere to the required payment dates until services are paid in full.  Special arrangements may be made by Pecan Valley Chiropractic Center.

Patients With Insurance/ Medicare:  We bill most insurance carriers and Medicare for you when proper paperwork is provided to us.  Co-payments and deductibles are due at the time of service.  If an insurance carrier has not paid within 60 days of billing, or denies payment, all professional fees are due and payable in full from you unless special arrangements have been made with Pecan Valley Chiropractic Center.

Accident Cases:  You must present Personal Injury Protection (PIP) or Medpay from your auto insurance or a Letter of Protection (LOP) from your attorney for any accidents.  This must be presented on the initial visit unless special arrangements are made with Pecan Valley Chiropractic Center.  We do not accept any third-party payors unless direct payment to Pecan Valley Chiropractic Center is agreed upon in writing prior to treatment.

Non-Covered Services:  Any care not paid for by your existing insurance coverage will require payment in full.  Payment arrangements will be made by Pecan Valley Chiropractic Center upon notice of insurance claim denial.

Missed Appointments:  In fairness to other patients and the doctors, if you are unable to make your appointment, please give our office 4 hours notice to reschedule or cancel an appointment.  Emergencies and work schedules are understandable.  You may be charged $25.00 for consecutive no-show appointments.

Assignment of Benefits:  I hereby assign all medical payments to Pecan Valley Chiropractic Center for services rendered.  A photocopy of this assignment is to be considered as valid as an original.  I understand that I am financially responsible for all charges whether or not paid by said payor.  I hereby authorize said assignee to release all information necessary to secure payment.  


I have read and agree to the above financial policy and understand that I am ultimately responsible for any unpaid balances.


_______________________________________________            ____________________
Print Patient Name                                                                           Date

_______________________________________________            
Patient Signature            
                
_______________________________________________            ____________________
Print Parent/ Guardian Name                                                                     Date
_______________________________________________            
Parent/ Guardian Signature    

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