WELCOME TO OUR CLINIC. We specialize in assisting our  patients to achieve their highest level of health through our spinal  and postural corrective programs. Our approach is very unique and  advanced from other rehabilitative programs. This allows our  patients to achieve far superior results compared to most other  systems.

Please fill out the following information thoroughly This will allow the doctor to determine if you are a case we can  accept. Please feel free to ask any questions if you need  assistance. We look forward to serving you. 

PURPOSE OF THIS VISIT 

EXPERIENCE WITH CHIROPRACTIC 

HEALTH LIFESTYLE

PLEASE LIST ALL MEDICATIONS YOU ARE  CURRENTLY TAKING (​PRESCRIPTION AND Over the Counter)

HEALTH CONDITIONS 

Abnormal postural habits or distortions are the result of trauma or stress to the body that have misaligned the vertebrae in your spine. When these vertebrae are twisted from their normal position, they will cause stress to the spinal cord and the delicate nerves that pass between the vertebrae. These misalignments are called subluxations (sub­lux­a­shuns). It has been extensively documented that subluxations, causing stress to your nerves, will weaken and distort the overall structure of your spine. This results in a weakened and distorted POSTURE. Postural distortions have many serious and adverse affects on your overall health. The most common and detrimental postural distortion is called Forward Head Syndrome(a“hunchedforward” posture starting in the neck and progressively moving down your spine weakening the entire body). 

Please Underline any health condition you may be experiencing, ​NOW​ or in the PAST ​ ​

FAMILY HEALTH HISTORY

AUTHORIZATION ​CARE

I authorize and agree to allow the doctor and/or assistant to work with my spine through the use spinal adjustments and 
rehabilitative exercises for the sole purpose of postural and structural restoration of normal biomechanical and neurological 
function.

I understand that I am responsible for all fees incurred for the services provided, and agree to 
ensure full payment of all charges.

The Doctor and/or assistant will not be held responsible for any health conditions or diagnoses which are pre­existing, given 
by another health care practitioner, or are not related to the spinal structural conditions diagnosed at this clinic.
 
I also clearly understand that if I do not follow the doctors and/or assistant’s specific recommendations at this clinic that I will 
not receive the full benefit from these programs, and that if I terminate my care prematurely that all fees incurred will be due 
and payable at that time. I authorize the assignment of all insurance benefits be directed to the doctor and/or assistant for all 
services rendered. 

IN CASE OF EMERGENCY

MASTER ASSIGNMENT, LIEN, AND AUTHORIZATION OF  INSURANCE /ATTORNEY PAYMENTS 

To Whom It May Concern:

hereby authorize and direct you, my insurance company, and/or my attorney to pay directly to Integrative Chiropractic Health & Wellness such sums as may be due and owed to Integrative Chiropractic Healt & Wellness for services rendered to me, both by reason of an accident or illness, and by reason of any other bills that are due to Integrative Chiropractic Health & Wellness, and to withhold such sums from any disability benefits, medical payment benefits, No Fault benefits, health and accident benefits, worker’s compensation benefits, or any other insurance benefits obligated to reimburse me, or from any settlement, 

judgment or verdict on my behalf as may be necessary to adequately protect Integrative Chiropractic Health & Wellness​. I hereby further give a lien to Integrative Chiropractic Health & Wellness against any and all insurance benefits name herein, and any and all proceeds of settlement, judgment or verdict which may be paid to me as a result of the injuries or illness for which I have been treated by Integrative Chiropractic Health & Wellness​ This is to act as an assignment of my rights and benefits to the extent of Integrative Chiropractic Health & Wellness’s​ services rendered.

 

In the event my insurance company is obligated to make payments to me upon the charges made by Integrative Chiropractic Health & Wellness for their services, refuses to make such payments, upon demand by me or Integrative Chiropractic Health & Wellness​, I hereby assign and transfer to Integrative Chiropractic Health & Wellness any and all causes of action that I might have or that might exist in my favor against such company, and authorize Integrative Chiropractic Health & Wellness ​to prosecute said cause of action either in my name or in the Integrative Chiropractic Health & Wellness’s​ name, and further I authorize Integrative Chiropractic Health & Wellness​ to compromise, settle, or otherwise resolve said claim or cause of action as 

they see fit. 

 

I understand that I remain personally responsible for the total amounts due to Integrative Chiropractic 

Health & Wellness for their services rendered. I further understand and agree that this Master Assignment, Lien, and Authorization does not constitute any consideration for Integrative Chiropractic Health & 

Wellness to await payments and may demand payments from me immediately upon rendering services at their 

option. 

 

I authorize Integrative Chiropractic Health & Wellnessto release any information pertinent to my case to any insurance company, adjuster or attorney to facilitate collection under this Master Assignment, Lien and Authorization.

 

I hereby state and agree that a photocopy of this document we be as valid and binding on all parties involved as the original copy.

FORMS OF PAYMENT

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and me. I clearly understand and agree that all services rendered after my insurance’s contracted annual agreement, are charged directly to me and that I am personally responsible for payments.

 

I understand that I am responsible for my contracted payment at the time of service. I also understand that if I suspend or terminate my care and treatment any fees for professional services rendered me will be immediately due and payable. I will be responsible for any costs of collection, attorney’s fee or court costs required to collect my bill.

 

We accept cash, personal checks, VISA, MasterCard, American Express, and DISCOVER. Any bounced checks and fees will be my responsibility and will be paid in full. Any credit arrangements must be authorized in advance.

 

Other options are available if your care is covered by Workers Compensation, Medicare, Personal Injury, or the result of an automobile accident. We will not become involved in disputes with your insurance company or attorney regarding deductible, co-payments, covered charges, secondary insurance, “usual and customary” charges, “medical necessity”, etc. other than to supply factual information.

HIPAA GUIDELINES 

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 in which we may have to use or disclose your health care information. We may have to disclose your PHI to another healthcare provider or hospital if it is necessary to refer you to them for the diagnosis, assessment, or treatment. We may have to disclose your health information and billing records to another party if they are potentially responsible for the payment of your services.   

 

We may need to use your health information within our own practice for quality control or other operational purposes. We may need to use your PHI to remind you of appointments, send you a birthday card, send you a thank you, acknowledge your referral, send you a welcome to the office letter, and invite you to participate in office workshops, or send promotional information. We have a more complete notice that provides a detailed description of how your PHI may be used or disclosed. You have the right to revise that notice before you sign this consent form. We reserve the right to change our privacy practices as described in that notice.

YOUR RIGHTS

You have the right to request that we do not disclose your PHI to specific individuals, companies, or organizations. If you would like to place any restrictions on the use or disclosure of your PHI please let us know in writing. We are not required to agree with your restrictions. However, if we agree with your restrictions, the restriction is binding upon us. You may revoke your consent to us at any time; However, your revocation must be in writing. We will not be able to honor you revocation request if we have already released your PHI before we receive your request. If you were required to give your authorization as a condition of obtaining insurance, they may have the right to your PHI if they decide to contest any of your claims. I have read your consent policy and agree to its terms. I am also acknowledging that I have received a copy this notice if requested. 

HEALTH CARE AUTHORIZATION FORM 

THE FOLLOWING AUTHORIZES INTEGRATIVE CHIROPRACTIC HEALTH & WELLNESS TO USE AND/OR DISCLOSE PROTECTED HEALTHCARE INFORMATION IN ACCORDANCE WITH THE FOLLOWING SPECIFIC AUTHORIZATIONS:

 

I give permission to Integrative Chiropractic Health & Wellness to use my name, address, phone numbers and clinical records to contact me with birthday cards, holiday related cards, health related emails messages and information about treatment alternatives or other health related information as  well as any advertisements, newsletters or patient of the week/month postings.  I also give Integrative Chiropractic Health & Wellness permission to use pre/post posture pictures and x-rays for awareness and office teaching.

 

I give permission to Integrative Chiropractic Health & Wellness to treat me in an open room where other patients are also being treated. I am aware that other persons in the office may overhear some of my protective health care information during the course of my treatment. Should I need to speak with a doctor or physical therapist in private, the doctor or therapist will provide a private room for these conversations.

 

By signing the following you are giving Integrative Chiropractic Health & Wellness permission to use and disclose your protected health information in accordance with the directives listed above.

ACKNOWLEDGEMENT OF RECEIPT & NOTICE OF PRIVACY  PRACTICES 

Understand and have been provided with a notice of (print name) information practices that provides me a more complete description of information uses and disclosures, I understand that I have the following rights and privileges: 

* The right to review the notice prior to signing this consent 

* The right to object to the use of my health care information for directory purpose 

* The right to request restrictions as to how my health care information may be      

* Used or disclosed in this office to carry out treatment, payment, or health care Operations

INSURANCE INFORMATION

I clearly understand that all insurance coverage, whether accident, work related, or general coverage is an arrangement between my insurance carrier and myself. If this office chooses to bill any services to my insurance carrier that they are performing these services are strictly as a convenience to me. The Doctor's office will provide any necessary reports or required information to aid in insurance reimbursement of services, but I understand that insurance carriers may deny my claims and that I am ultimately responsible for any unpaid balances. Any monies received will be credited to my account. 

RADIOGRAPH CONSENT (X­-Ray)

do hereby give my consent to allow Integrative Chiropractic Health & Wellness and its representatives, as deemed by the examining physician to take radiographs of my spine and/or extremities.

FOR FEMALES ONLY

WORK HISTORY

YOUR PRESENT JOB INVOLVES

HAVE YOU MISSED ANY WORK AS A RESULT OF YOUR CONDITION? 

ROLAND-MORRIS LOW BACK PAIN INDEX