New Patient Form

INSURANCE INTAKE















MARITAL STATUS:OnS OnM OnD OnW
Sex: OnM OnF

INSURANCE INFORMATION


TYPE: (CIRCLE ONE)OnMEDICAL OnAUTO OnHOME OWNERS OnOTHER









SECONDARY INSURANCE INFORMATION












ASSIGNMENT OF BENEFITS




PATIENT MEDICAL HISTORY QUESTIONNAIRE





Referring Doctor




Referring Family Doctor





















OnDiabetes
OnHigh Blood Pressure
OnCoronary artery disease
OnVascular disease
OnEmphysema
OnHeart diseaseattacks
OnCongestive heart failure
OnThyroid disease
OnDepression
OnLyme disease
OnBleeding disorder
OnSeizures
OnGastric reflux
OnMultiple Sclerosis
OnEnlarged prostate
OnHepatitis
OnLiver disease
OnOsteoarthritis
OnRheumatoid arthritis
OnStomach ulcers
OnKidney disease
OnAsthma
OnCOPE
OnCancer
OnScoliosis
OnBleeding disorder
OnCoronary artery disease
OnHepatitis
OnCancer
OnHeart DiseaseAttacks
OnSeizures
OnLung disease
OnRheumatoid arthritis
OnKidney disease
OnMalignant hyposthenia
OnScoliosis
OnAsthma

Past Surgical History ( Please (write left or right if applicable) then list the date of surgery)













OnCurrent Smoker
OnFormer Smoker
OnNever Smoked
OnPipe Smoker
OnCigar Smoker
On3 cigarettes or less per day
On12 a pack per day
OnMore than a pack per day
Social only
OnSeveral times per week
OnEveryday
OnIV Drugs
OnPills
OnMarijuana
OnOther
OnGolf
OnTennis
OnFootball
OnSoccer
OnBaseball
OnBasketball
OnRun

OnConstitutional
OnFever
OnNight Sweats
OnWeight loss
OnEyes
OnRed Eyes
OnBlurring vision
OnVision loss
OnEars/Nose/Mouth
OnNose bleeds
OnSore throat
OnHearing loss
OnCardiovascular
OnChest pain
OnPalpations
OnLeg swelling
OnRespiratory
OnShortness of breath
OnChronic cough
OnWheezing
OnGastrointestinal
OnNausea
OnVomiting
OnDiarrhea
OnGenitourinary
OnBurning w/ urination
OnBlood in urine
OnUrinary incontinence
OnSkin
OnRash
OnHives
OnSkin infection
OnNeurological
OnHeadache
OnTremor
OnSeizures
OnPsychiatric
OnDepression
OnPanic attacks
OnSuicidal ideation
OnEndocrine
OnExcessive thirst
OnCold intolerance
OnExcessive sweating
OnHematological/Lymph
OnEasy bruising
OnSwollen glands
OnEasy bleeding
OnAllergy/Immune
OnRunny nose
OnSinus congestion
OnItchy eyes



Informed Consent to Chiropractic & Physical Therapy

Soreness: l am aware that, like exercise, it is common to experience muscle soreness in the first few treatments.
Fractures/Joint injury: I further understand that an Isolated cases underlying physical deformities or pathologies like weak bones from osteoporosis may render the patient susceptible to Injury. When osteoporosis, degenerative disc, or other abnormality is detected, this office will proceed with extra caution.
Stroke: Although strokes happen with some frequency In our world, stroke from chiropractic adjustments are rare. I am aware that nerve or brain damage including stroke to reported to occur once in one million to once in ten million treatments.
Physical Therapy Burns: Some of the therapies used in this office generate heat and may rarely cause a burn. Despite precautions, If a burn is obtained, there will be a temporary Increase of pain and possible blistering. This should be reported to the doctor. Tests have been performed on me to minimize the risk of complications from treatment, and I freely assume these risks.

Treatment Results

I also understand that there are beneficial effects associated with these treatment procedures Including decreased pain, improved mobility and function, and reduced muscle spasm. However, I appreciate there is no certainty that I will achieve these benefits. I agree to the performance of these procedures by my doctor and such other persons of the doctor's choosing.

ALTERNATIVE TREATMENTS AVAILABLE

Reasonable alternatives to these procedures have been explained to me Including rest, home applications of therapy, prescription or over-the-counter medications, exercise and possible surgery.

Consent to evaluate and treatment of a minor child(if applicable)

I, being the parent or legal guardian of have read and fully understand the above Informed Consent and hereby grant permission for my child to receive chiropractic care and/or physical therapy. I have read or have had read to me the above explanation of chiropractic treatment. Any questions I had regarding these procedures have been answered to my satisfaction PRIOR TO MY SIGNING THIS CONSENT FORM. I have made my decision voluntarily and freely.
To attest to my consent to these procedures, i hereby affix my signature to this authorization for treatment.



ALLCURE SPINE AND SPORTS MEDICINE

FINANCIAL POLICY AGREEMENT




An Accounting of Disclosures:

Request Restrictions:

You have the right to request a restriction or limitation the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a procedure that you had. We ask that you submit these requests in writing. Except under Specific circumstances, we are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment or is required by law. We must agree to restrict the disclosure of protected health information to a health plan for purposes of carrying out payment or health care operations (as defined by HEPPA) if the information pertains solely to a health care item or service for which we have been paid by you out-of-pocket, and in full.

Request Confidential Communications:

You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. We will agree to the request to the extent that it is reasonable for us to do so. For example, you can ask that we use an alternative address for billing purposes. We ask that you submit your request in writing.

A Paper Copy of This Notice:

You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy. To exercise any of your rights, please obtain the required forms from the Privacy Officer and submit your request in writing.

Complaints:

If you believe your privacy rights have been violated, you may file a complaint with us by calling (732) 521-9222 and asking for the Privacy Officer or by contacting the Secretary of the Federal Department of Health and Human Services. All complaints must be also submitted in writing. You will not be penalized for filing a complaint

Other Uses of Medical Information

Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. However, we are unable to take back any disclosures we have already made with your permission and we are required to retain our records of the care that we provided you.



HIPPA Authorization


OnLeave message on my answering machine
OnLeave message with spouse
OnLeave message with anyone who answers the phone
OnCan fax information to my home
OnCan fax information to my work place
OnCan mail information to my home
OnCan mail information to my work place
OnCan request your Medicare information from prior facilitiesPhysicians

You can leave messages confirming my appointments as described below:

OnLeave message on my answering machine
OnLeave message with my spouse
OnLeave message with anyone who answers phone