Wright Chiropractic Health Center Patient Information and ...
Chiropractic Case History/Patient Information...arrangements have been made with Kaumeyer...
Transcript of Chiropractic Case History/Patient Information...arrangements have been made with Kaumeyer...
1 Dr. Gregory T. Kaumeyer, D.C., C.C.S.P., C.M.E.
100 Ridgeway St., Suite 8
Hot Springs, Arkansas 71901
P 501-463-9477
F 501-463-9478
Chiropractic Case History/Patient Information
Date:__________________ Patient #___________ Doctor:___________________
Name:__________________________ Social Security #__________________Home Phone: _______________
Address:____________________________________City:___________________ State:______ Zip:___________
E-mail address:____________________________Fax # __________________ Cell Phone:__________________
Age:_______ Birth Date:___________ Race:______ Marital: M S W D
Occupation:_________________________ Employer:________________________________________________
Employer's Address:__________________________________ Office Phone:_____________________________
Spouse:___________________ Occupation:________________ Employer:_______________________________
How many children?____________Names and Ages of Children:________________________________________
___________________________________________________________________________________________
Name of Nearest Relative:________________________ Address:______________________Phone:___________
How were you referred to our office?______________________________________________________________
Family Medical Doctor:_________________________________________________________________________
When doctors work together it benefits you. May we have your permission to update your medical doctor regarding
your care at this office?___________
Please check any and all insurance coverage that may be applicable in this case: Major Medical Worker's Compensation Medicaid Medicare Auto Accident Medical Savings Account & Flex Plans Other
Name of Primary Insurance Company:___________________________________________________________ Name of Secondary Insurance Company (if any):___________________________________________________ AUTHORIZATION AND RELEASE: I authorize payment of insurance benefits directly to the chiropractor or chiropractic office. I authorize the doctor to release all information necessary to communicate with personal physicians and other healthcare providers and payors and to secure the payment of benefits. I understand that I am responsible for all costs of chiropractic care, regardless of insurance coverage. I also understand that if I suspend or terminate my schedule of care as determined by my treating doctor, any fees for professional services will be immediately due and payable.
The patient understands and agrees to allow this chiropractic office to use their Patient Health Information
for the purpose of treatment, payment, healthcare operations, and coordination of care. We want you to know
how your Patient Health Information is going to be used in this office and your rights concerning those
records. 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.
Patient's Signature:_____________________________________________________ Date:________________
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HISTORY OF PRESENT AND PAST ILLNESS:
Chief Complaint: Purpose of this appointment:_______________________________________________
Date symptoms appeared or accident happened:_________________________________________
Is this due to: Auto___ Work____ Other________________________________________________
Have you ever had the same or a similar condition? Yes No If yes, when and describe:______________
___________________________________________________________________________________________
Days lost from work:_________________ Date of last physical examination:_________________________
Do you have a history of stroke or hypertension?_____________________________________________ Have you had any major illnesses, injuries, falls, auto accidents or surgeries? Women, please include information
about childbirth (include dates): _________________________________________________________________
___________________________________________________________________________________________ Have you been treated for any health condition by a physician in the last year? Yes No
If yes, describe:_______________________________________________________________________________
What medications or drugs are you taking?_________________________________________________________
___________________________________________________________________________________________
Do you have any allergies to any medications? Yes No
If yes, describe:_______________________________________________________________________________
Do you have any allergies of any kind? Yes No
If yes, describe:______________________________________________________________________________
Do you have any Congenital Condition? ___Yes ___ No If YES, Describe ______________________________ Women: Are you pregnant?___________________
Have you had or do you now have any of the following symptoms/conditions? Please indicate with the letter N if you have these conditions now or P if you have had these conditions previously.
N = Now P = Previously
Headaches______ Frequency ________ Loss of Balance __________ Neck Pain ________ Fainting __________ Stiff Neck ________ Loss of Smell __________ Sleeping Problems ________ Loss of Taste __________ Back Pain ________ Unusual Bowel Patterns __________ Nervousness ________ Feet Cold __________ Tension ________ Hands Cold __________ Irritability ________ Arthritis __________ Chest Pains/Tightness ________ Muscle Spasms __________ Dizziness ________ Frequent Colds __________ Shoulder/Neck/Arm Pain ________ Fever __________ Numbness in Fingers ________ Sinus Problems __________ Numbness in Toes ________ Diabetes __________ High Blood Pressure ________ Indigestion Problems __________ Difficulty Urinating ________ Joint Pain/Swelling __________ Weakness in Extremities ________ Menstrual Difficulties __________
PATIENT NAME ____________________________________________ DATE ____________________
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Breathing Problems ________ Weight Loss/Gain __________ Fatigue ________ Lights Bother Eyes ________ Loss of Memory __________ Ears Ring ________ Buzzing in Ears __________ Broken Bones/Fractures ________ Circulation Problems __________ Rheumatoid Arthritis ________ Seizures/Epilepsy __________ Excessive Bleeding ________ Low Blood Pressure __________ Osteoarthritis ________ Osteoporosis __________ Pacemaker ________ Heart Disease __________ Stroke ________ Cancer __________ Ruptures ________ Coughing Blood __________ Eating Disorder ________ Alchoholism __________ Drug Addiction ________ HIV Positive __________ Gall Bladder Problems ________ Depression __________ Ulcers ________
SOCIAL HISTORY Please indicate beside each activity whether you engage in it:
OFTEN= “O” SOMETIMES= “S” NEVER= “N”
__________ Vigorous Exercise _________ Family Pressures __________ Moderate Exercise _________ Financial Pressures __________ Alcohol Use _________ Other Mental Stresses __________ Drug Use _________ Other (specify)______ __________ Tobacco Use ___________________________ __________ Caffeine ____________________________ __________ High Stress Activity
Patient's Signature:_____________________________________________________ Date:________________
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Kaumeyer Chiropractic Center
Medical Information Release Form
(HIPPA Release Form)
Name:__________________________________________ Date of Birth:__________________
Release of Information
() I authorize the release of information including diagnosis and records of the examination rendered to
me and claims information. This information may be released to:
() Spouse________________________________________
() Child(ren)______________________________________
() Other_________________________________________
() Information is not to be released to anyone.
This Release of Information will remain in effect until terminated by me in writing.
Messages
Please call () My home () My work () My cell number:_______________
If unable to reach me:
() You may leave a detailed message
() Please leave a message asking me to return your call
()___________________________________________
The best time to call me is (day)____________________ between (time)__________________
Signed:__________________________________________ Date:_____________________
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Kaumeyer Chiropractic Center, LLC
Dr. Gregory T. Kaumeyer, D.C., C.C.S.P., C.M.E.
100 Ridgeway Street, Suite 8 * Hot Springs, Arkansas 71901
501-463-9477
Payment Policy
Thank you for choosing us as your primary care provider. We are committed to providing you
with quality and affordable health care. Because some of our patients have had questions
regarding patient and insurance responsibility for services rendered, we have been advised to
develop this payment policy. Please read it, ask us any questions you may have, and sign in the
space provided. A copy will be provided to you upon request.
1. Insurance. We participate in most insurance plans, including Medicare. If you are not insured by a plan we do business with, payment in full is expected at each visit. If you are insured by a plan we do business with, but don’t have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.
We do accept Auto Accidents (medical pay and 3rd party). However, unless other arrangements have been made with Kaumeyer Chiropractic Center, payment is expected from the patient no later than 60 days, from release of treatment. This is the patient’s responsibility, not auto Insurance company.
2. Copayments and Deductibles. All co-payments and deductibles must be paid at time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patient’s can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit.
3. Non-covered services. Please be aware that some, and perhaps all, of the services you receive may be non-covered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of the visit.
4. Proof of Insurance. All Patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver’s license and current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of the claim.
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5. Claims Submission. We will submit your claims and assist you in any way we reasonably
can to help get your claims paid. Your insurance company may need you to supply certain
information directly. It is your responsibility to comply with their request. Please be
aware that the balance of your claim is your responsibility, whether or not your insurance
company pays your claim. Your insurance benefit is a contract between you and your
insurance company; we are not party to that contract.
6. Coverage changes. If your insurance changes, please notify us before your next visit so
we can make the appropriate changes to help you receive your maximum benefits. If your
insurance company does not pay your claim in 45 days, the balance will automatically be
billed to you.
7. Nonpayment. If your account is over 90 days past due, you will receive a letter stating
that you have 20 days to pay your account in full. Partial payments will not be accepted
unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may
refer your account to a collection agency and you and your immediate family members
may be discharged from this practice. If this is to occur, you will be notified by regular and
certified mail that you have 30 days to find alternative medical care. During that 30 day
period, our physician will only be able to treat you on an emergency basis.
8. Missed appointments. Our policy is to charge for missed appointments not canceled
within a reasonable amount of time. These charges will be your responsibility and billed
directly to you. Please help us to serve you better by keeping your regularly scheduled
appointment.
Our practice is committed to providing the best treatment to our patients. Our prices are
representative of the usual and customary charges for our area. Thank you for
understanding our payment policy. Please let us know if you have any questions or
concerns.
I have read and understand the payment policy and agree to abide by its guidelines:
____________________________________ _________________
Signature of patient or responsible party Date