Intake Paperwork

Patient Information

Emergency Contact

My Health Insurance

Verification of eligibility and/or benefit information is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility, any claims received during the interim period and the terms of the member’s certificate of coverage applicable on the date services were rendered.

Reason For This Visit

Top 2 chief complaints:

Goals for my Care

Our main question for you is- Why are you really here? People visit our office for many reasons. While you may be here to find relief from pain or other symptoms, our Providers want to know what your “big picture” is. Is your pain limiting you from participating in activities? Is it preventing you from living your life to its fullest? If so, how?

Past Medical History

Please provide information about your infancy:

If applicable:

Health Habits

Patient Social History:

Exposure at home or at work to:

Family Medical History:

Functional Rating Index

In order to properly assess your musculoskeletal condition, we must understand how your neck, leg and/or back problems have affected your ability to manage ever day activities. For each item below, please choose which most closely describes your condition today.

Authorization for Care

I hereby authorize the Provider to work with my condition using physical medicine such as adjustments to my spine, trigger point injections, joint injections or other medical recommendations, as he or she deems appropriate.

I clearly understand and agree that all the services rendered to me are charged directly to me and that I am personally responsible for all payment. I agree that I am responsible for all the bills incurred at this office. The Provider will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. I also understand that if I suspend or terminate my care, any fees for professional services rendered to me will become immediately due and payable. I hereby authorize assignment of my insurance rights and benefits (if applicable) directly to the provider of services rendered.

Patient Health Information Consent Form

We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we begin any health care operations, we must require you to read and sign this consent form stating that you understand and agree with how your records will be used. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information, we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent.

1. The patient understands and agrees to allow this chiropractic office to use their Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operations, and coordination of care. As an example, the patient agrees to allow this medical office to submit requested PHI to the Health Insurance Company (or companies) provided to us by the patient for the purpose of payment. Be assured that this office will limit the release of all PHI to the minimum needed for what the insurance companies require for payment.
2. The patient has the right to examine and obtain a copy of his or her own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI. Our office is not obligated to agree to those restrictions.
3. A patient's written consent needs only be obtained one time for all subsequent care given the patient in this office.
4. The patient may provide a written request to revoke consent at any time during care. This would not affect the use of those records for the care given prior to the written request to revoke consent but would apply to any care given after the request has been presented.
5. For your security and right to privacy, all staff have been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures in our office. We have taken all precautions that are known by this office to assure you that your records are not readily available to those who do not need them.
6. Patients have the right to file a formal complaint with our privacy official about any possible violations of these policies and procedures.
7. If the patient refuses to sign this consent for the purpose of treatment, payment and health care operations, our office has the right to refuse to give care

I have read and understand how my Patient Health Information will be used and I agree to these policies and procedures.

X-ray Consent

This is to certify that the Provider has my permission to perform an X-ray evaluation. To the best of my knowledge I am not pregnant and I have been advised that x-ray can be hazardous to an unborn child. If the overseeing doctor chooses not to use gonad shielding equipment (so as to not disrupt the assessment of anatomy radiographed), I give full consent to continue with the procedure.

ASSIGNMENT OF HEALTH PLAN BENEFITS AND RIGHTS AS WELL AS AN APPOINTMENT AND/OR DESIGNATION AS MY PERSONAL REPRESENTATIVE AND AN ERISA/PPACA REPRESENTATIVE AND BENEFICIARY

I understand and agree that (regardless of whatever health insurance or medical benefits I have), I am ultimately responsible to pay Modern Movement Medicine as well as all employees, employers, representatives, and agents thereof(hereinafter collectively referred to as “Healthcare Provider”) the balance due on my account for any professional services rendered and for any supplies, tests, or medications provided. I hereby authorize payment of, and assign my rights to, any health insurance or medical plan benefits directly to Healthcare Provider for any and all medical/healthcare services, supplies, tests, treatments, and/or medications that have been or will be rendered or provided; as well as designating and appointing Healthcare Provider as my beneficiary under all health insurance or medical plans which I may have benefits under. I hereby authorize the release of any health status, conditions, symptoms or treatment information contained in your records that is needed to file and process insurance or medical plan claims, to pursue appeals on any denied or partially paid claims, for legal pursuit as to any unpaid or partially paid claims, or to pursue any other remedies necessary in connection with same. I hereby assign directly to Healthcare Provider all rights to payment, benefits, and all other legal rights under, or pursuant to, any health plan (including, but not limited to, any ERISA governed plan/insurance contract, PPACA governed plan/insurance contract) rights that I (or my child, spouse, or dependent) may have under my/our applicable health plan(s) or health insurance policy(ies). I also hereby appoint and designate that Healthcare Provider can act on my/our behalf, as my/our Personal Representative, ERISA Representative, and PPACA Representative as to any claim determination, to request any relevant claim or plan information from the applicable health plan or insurer, to file and pursue appeals and/or legal action (including in my name and on my behalf) to obtain and/or protect benefits and/or payments that are due (or have been previously paid) to either Healthcare Provider, myself, and/or my family members as a result of services rendered by Healthcare Provider, and to pursue any and all remedies to which I/we may be entitled, including the use of legal action against the health plan, the insurer, or any administrator. I hereby also declare that Healthcare Provider is my/our beneficiary regarding my/our health plan as contemplated by both ERISA and PPACA, and that Healthcare Provider can pursue any and all rights that I/we may have under state and/or federal law regarding my/our health plan. This assignment, appointment, and designation will remain in effect unless revoked by me in writing. It is my intent that the effective date of this document shall relate back to include all services, supplies, test, treatments, or medications that have been previously provided by Healthcare Provider. A photocopy or scan or this document is to be considered as valid and as enforceable as the original.

Office Fee Schedule and Financial Policy (Out of Pocket Patients)

*Naturopathic Services such as pelvic floor therapy and craniosacral therapy are best received within a 50-minute office
visit.

Financial Policy

We are committed to providing you with the best chiropractic and integrative medical care possible in a caring environment and have established our financial policies to achieve that goal. The following plans are designed to be the most costeffective way to keep you and your family as healthy as possible.

SENIOR DISCOUNT: Modern Movement Medicine follows Medicare guidelines and fees offering services at 1.5 times the current rate. Anyone over the age of 65 will receive this discount. It is important to note that Medicare fees are based on the number of areas in the spine adjusted on that day. Current rates for 1-2 regions are $32.19, and 3-4 regions are $46.70. Extremity adjustments (anything outside of the spine) is an additional $20. These rates are subject to change.

Personal Financial Responsibility (Auto Accident or Workers Compensation)

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that the Providers will prepare any necessary reports and forms to collect from the insurance company and that any amount authorized to be paid directly to Modern Movement Medicine will be credited to my account on receipt. However, if services rendered are not paid for, you the patient are personally responsible for payment.

Insurance- If you do not have health insurance, or choose not to use your health insurance, you will be given a receipt indicating the total amount that you have paid for services at Modern Movement Medicine during the year. We have found it is easier for your record keeping, and ours, if we give you receipts at the end of your first visit and then once a month after that. Just send your receipts with a copy of your claim form to your insurance company, and they will communicate with you about your reimbursement. ***If a special situation arises, such as an auto accident or a worker’s compensation injury, we will bill to the third party.

* Payment is due at the time of service unless other payment arrangements have been made in advance. We accept cash, check, Visa, MasterCard and CareCredit. There is a $30 fee on all returned checks. Any balances over $200 and more than 60 days old are considered past due and will be sent to a collections agency. *

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor’s office of any changes in my medical status. I also authorize the healthcare staff to perform the necessary services I may need.

Personal Representative Request Form

An individual’s personal representative is someone authorized under written permission from the individual, State, or other applicable law to act on behalf of the individual in making health care related decisions and having access to PHI. The HIPAA Privacy Rule requires covered entities to treat a personal representative as they would the patient themselves, particularly around uses and disclosures of the patient’s protected health information.

Personal Representative Information