Bahnemann Family Chiropractic, PC: Registration and History

PAYMENT INFORMATION __ Auto Insurance Claim __Commercial Insurance __No Insurance (Self Pay) __Medicare __Worker’s Compensation If this is a Commercial Insurance Claim, please fill out the following “Assignment and Release” and provide your health insurance card to the receptionist so she can make a copy of the card. We will file the insurance claim for you. ASSIGNMENT AND RELEASE

I, the undersigned, certify that I (or my dependent) have insurance coverage with _______________________and assign directly to Bahnemann Family Chiropractic, PC all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

___________________________________________________ Responsible Party Signature ________________________________ _______________ Relationship Date

PATIENT INFORMATION

Date____________________

Patient_________________________________________

Patient Social Security ____________________________

Address________________________________________

_______________________________________________

City State Zip

Email__________________________________________

Would you like to receive correspondence via e-mail? Y/N

Sex: M F Age_____ Birth Date___________________

Single Married Widowed Separated Divorced

Occupation______________________________________

Employer_______________________________________

Spouse’s name__________________________________

Birthdate___________Occupation____________________

Whom may we thank for referring you?________________

_______________________________________________

PHONE NUMBERS

Home____________ Work_____________ Ext._____

Cell_______________ Best number to reach you

May we remind you of your next appointment via text msg or

e-mail? (Circle one) Yes/ No

If yes, specify info: ____________________________

IN CASE OF EMERGENCY, CONTACT

Name______________________Relationship_______

Phone____________________ Alt Ph_____________

ACCIDENT INFORMATION

Is condition due to an accident? __Y __N Date________

Type of accident __Auto __Work __Home __Other

To whom have you made a report of your accident?

__Auto Ins __Employer __Work Comp. __Other

Information for Auto Claims Only:

Name of Auto Insurance:__________________________

Claim #__________________Ph #__________________

Adjuster’s Name:________________________________

ACCIDENT DIAGRAM

NOTICE OF DOCTOR'S LIEN LIEN AGREEMENT

I do hereby authorize Dr. Kerri Bahnemann, DC to furnish you, __________________________ Insurance Company, which will be referred to as “my insurance company” throughout this document, with a full report of her examination, diagnosis, treatment, prognosis, etc., of myself in regard to the accident on _________, in which I was recently involved.

I hereby authorize and direct you, my insurance company to pay directly to said doctor such sums as may

be due and owing her for medical service rendered me both by reason of this accident and by reason of any

other bills that are due her office, and to withhold such sums from any settlement, judgment or verdict which

may be necessary to adequately protect said doctor. I hereby further give a first party lien on my case to Dr.

Kerri Bahnemann, DC against any and all proceeds of my settlement, judgment or verdict which I have been

treated of injuries in connection therewith.

I hereby direct any attorney to recognize and honor this lien and to pay you directly from the proceeds allocated to me in his attorney trust account at the time he receives them. I have personally served my attorney with a copy of this lien and as principal have put my attorney, as my agent, on notice regarding his responsibility in paying you.

I agree never to rescind this document and understand that a rescission will not be honored by my

insurance company. I hereby instruct that in the event another insurance company is substituted or added

in this matter, the new insurance, company honor this first party lien as inherent to the settlement and

enforceable upon the case as if it were initially executed by them.

I fully understand that l am directly and fully responsible to the said doctor for all medical bills submitted for

her for service rendered to me and that this first party lien agreement is made solely for the said doctor's

additional protection and in consideration of her awaiting payment. I further understand that such payment

is not contingent on any settlement, judgment or verdict by which I may eventually recover said fees.

Please acknowledge this letter by signing below and returning it to the doctor's office. I have been advised

that if my insurance company does not wish to cooperate in protecting the doctor's interest, the doctor will

not await payment but will require me to make payments on a regular basis to keep my account current.

DOA: ____________________ Patient’s Name _____________________________

Claim #: __________________ Patient’s Signature ___________________________

The understanding being a representative of the _____________________Insurance Company of record

for the above patient does hereby agree to observe all the terms of the first party lien and agrees to withhold

such sums from any settlement, judgment, or verdict, as may be necessary to adequately protect the said

doctor above named and to execute this lien in the first party on behalf of Dr. Kerri Bahnemann, DC.

___________________ _______________________________

Date: Insurance Company Representative Signature

Bahnemann, DC Family Chiropractic PC

7610 N Union Blvd #125Colorado Springs, CO 80920

Bahnemann Family Chiropractic, PC

CONSENT TO TREATMENT

Health care providers are required to advise patients of the nature of the treatment to be provided, the risks and

benefits of the treatment, and any alternatives to the treatment.

There are some risks that may be associated with treatment, in particular you should note:

a. 'While rare, some patients have experienced rib fractures or muscle and ligament sprains or

strains following treatment;

b. There have been rare reported cases of disc injuries following cervical and lumbar spinal adjustment

although no scientific study has ever demonstrated such injuries are caused, or may be caused, by spinal

or soft tissue manipulation or treatment.

c. There have been reported cases of injury to a vertebral artery following osseous spinal

manipulation. Vertebral artery injuries have been known to cause a stroke, sometimes with

serious neurological impairment, and may, on rare occasion, result in paralysis or death. The

possibility of such injuries resulting from cervical spine manipulation is extremely remote;

Osseous and soft tissue manipulation has been the subject of government reports and multi-disciplinary studies

conducted over many years and have demonstrated it to be highly effective treatment of spinal conditions

including general pain and loss of mobility, headaches and other related symptoms.

Musculoskeletal care contributes to your overall wellbeing. The risk of injuries or complications from

treatment is substantially lower than that associated with many medical or other treatments, medications,

and procedures given for the same symptoms.

I acknowledge I have discussed the following with my healthcare provider:

a. The condition that the treatment is to address;

b. The nature of the treatment;

c. The risks and benefits of that treatment; and

d. Any alternatives to that treatment.

I have had the opportunity to ask questions and receive answers regarding the treatment.

I consent to the treatments offered or recommended to me by my healthcare provider, including osseous and

soft tissue manipulation. I intend this consent to apply to all my present and future care with ___Kerri

Bahnemann, BS, DC (health care providers name).

Dated this day of 20_____

Patient signature (or Legal guardian) Signature of Witness

Print Name Print Name:

Patient Health lnformation 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 will 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 chiropractic 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 need 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 has 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 that your records are not readily available to those we 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, the chiropractic physician has the right to refuse to give care.

8. From time to time we may send you birthday cards or letters use your name on a birthday list or use your name on a referral board in our office. By your signature below you have given us permission to do so.

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

_________________________________________ __________________________ Patient Name Date

_________________________________________ Patient Signature

Bahnemann Family Chiropractic PC