New Patient Packet

Chiropractic Case History/Patient Information

About this Patient

HISTORY OF PRESENT ILLNESS

Is this due to:*
Please select at least one option

ACCIDENTAL INJURY FORM

AUTO INJURY

Were you:
Were you struck from:
Did the car strike others involved?
Did the other car strike yours?
As a result of the accident, were traffic citations issued to you?

ON-THE-JOB INJURY

Did you report the injury to your foreman or employer?

OTHER

Check symptoms you have noticed since the accident:
Did you require post-accident hospitalization?
Have you lost any days of work?

INSURANCE INFORMATION

PERSONAL INJURY INSURANCE INFORMATION

You have notified our office that you were involved in a Motor Vehicle Accident. Due to the rising costs of medical services, you may not want to pay for each visit personally. As a courtesy to our patients, Dr.

Speaks will defer payment on the account provided that we receive your cooperation on the following:

1) Provide the following insurance information:

  • Insurance Information for the Person Responsible for the Accident
  • Personal Auto Insurance
  • Health Insurance
  • Attorney Information (if applicable)

2) Set up Personal Injury Protection Claim (if applicable)

3) Cooperate with our office in communicating with involved insurance carriers/attorneys

INFORMATION NEEDED:

Insurance Information for at Fault:
Personal Auto Insurance:
If you were a passenger, please provide the insurance information of person driving:
Health Insurance:
Attorney Information: (if applicable)

510 W. FM 1382

Cedar Hill, TX 75104

972.291.4455

Notice of Doctor's Lien and Irrevocable Assignment and Directive of Proceeds

I hereby authorize my health care provider, Expressions Chiropractic, hereinafter "Provider," to furnish to my attorney, insurance company or other person or entity involved in my claim with a full report of my case history, examination, diagnosis treatment, prognosis, or other medical/billing resulting in my treatment by Provider. I also authorize Expressions Chiropractic to disclose such information to its attorney and any billing or collection entity that it may retain.

I further, for good and valuable consideration of which is hereby acknowledged, assign and transfer, irrevocable, to provider all rights, title and interest that I may now have or that I may have in the future to any and all benefits, proceeds, and/or monies that may be due me from any third-party and/or payer, including but not limited to third party liability payers, personal injury protection (PIP) coverage, underinsured/ uninsured coverage, third partied and group health plans as a result of the accident or injury event for which Provider has rendered and/or will render medical goods and services on my behalf.

I further irrevocably assign entitlement to benefits, proceeds and/or monies to Provider and irrevocably grant a lien to the extent of my indebtedness to Provider and irrevocably direct any third –partied and/or payers, including but not limited to third-party liability payers, personal injury protection (PIP) coverage, Medpay, underinsured/uninsured coverage, homeowners coverage, third parties and group health plans to make benefits, proceeds and/or monies payable to include Provider. I additionally issue this directive that no money, check, draft, electronic transfer, or any other payment is to be made to myself or my attorneys or my heirs or assigns from the above listed third-parties and payers without including Expressions Chiropractic as a payee on such disbursements.

I further irrevocably direct my attorney representing me as a result of the accident, occurrence, or injury causing event to protect Provider's total charges out of any recovery that is obtained on my behalf by directing and forwarding payment of said recovery to Provider to the extent of my total indebtedness to Provider. I fully understand that my attorney shall abide buy this irrevocable assignment, directive, and notice without further consultation with me and shall disclose to Provider and/or its representatives, agents, independent contractors and attorneys any and all information related to my claim(s) and settlement, judgment, verdict or recovery.

I further agree to fully inform Provider to any and all potential third-parties and/or payers, personal injury protection (PIP) coverage, underinsured/uninsured coverage, third parties or group health plans that may be liable for my injuries and to provide the names and addresses of any attorney(s) that may represent me nor or in the future concerning this accident, occurrence or injury event. I fully understand that this irrevocable assignment, directive and notice or lien shall remain with respect to any future attorney that I retain.

I further agree to defend, indemnify, and hold harmless Provider against any payer(s) and its agents,  representatives, employees, officers, directors, partners, shareholders, affiliates, attorneys, subcontractors, independent contractors, heirs, assigns and all other persons, firms, corporations, associations, or partnerships or other entities from any and all claims, actions, cause of actions, damages, costs, expenses, compensation, or otherwise on account of or in any way growing out of the direct payment to provider. I fully understand that it is my sole responsibility to maintain any and all claims, causes of action, appeals, and conditions to recover against any and all potential third-parties and/or payers, including but not limited to third-party liability payers, personal injury protection (PIP) coverage, underinsured/uninsured coverage, third parties and group health plans.


I further fully understand and agree that regardless of my execution of this agreement, that I am directly and fully responsible to Provider for medical goods and services provided and/or that will be provided to me and that this agreement is made solely for additional protection to Provider and in consideration of Provider awaiting payment. It is hereby understood and agreed that my responsibility for payment is not contingent upon any settlement, claim, judgment, verdict, recovery or otherwise that I may obtain. I also understand that any payments made on my behalf, whether by insurance companies, attorneys, or myself, if less than the full amount of my outstanding balance, is only partial payment toward my account. Any such partial payment is not and will not be considered and "offer in compromise: or release me from my remaining balance owed to Expressions Chiropractic.

It is further understood and agree that I shall fully inform and notify any third parties and payers, including but not limited to third-party liability payers, personal injury protection (PIP) coverage, underinsured/uninsured coverage, third parties and group health plans and/or my attorneys, or Irrevocable Assignment, Directive and Notice.

I further agree to waive for two years after any settlement is reached the statute of limitations applicable to Provider's claims, causes of action, rights and/or remedies in collecting its total charges pursuant to this Irrevocable Assignment, Directive and Notice, or pursuant to any remedy available to Provider in collecting its total charges, damages, interest, court costs of collection and any other relief to which Provider in collecting its total charges, damages, interest, court costs of collection and any other relief to which provider may be entitled. In addition to any cause of action available under Texas law or any other applicable state's laws, I understand and agree that Provider may seek a recovery from me and my attorney, agents, heirs, or assigns for breach of contract if I do not comply with this agreement.

This Irrevocable Assignment, Directive and Notice of Lien shall be irrevocable upon execution by me.

PAST MEDICAL HISTORY

Have you ever been diagnosed as having or have suffered from? (Place a check mark by conditions that apply to you)

SOCIAL HISTORY

What percentage of time during the day (at home or at your job away from home) do you spend:

FAMILY HISTORY

Check if applicable to you:
How will you be paying for your visit?*
Please select one option

AUTHORIZATINO 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. If there is anyone you do not want to receive your medical records, please inform our office.

SUMMARY

If yes, when and how?
How long does it last?
5. Are there any other conditions or symptoms that may be related to your major symptom?
Are there other unrelated health problems?
6. Describe the pain:
8. What makes the problem worse?
10. WOMEN ONLY: Are you pregnant or is there any possibility you may be pregnant?

TELL US WHERE YOU HURT

. Please read carefully: Mark the areas on your body where you feel your pain. Include all affected areas. Mark areas of radiation. If your pain radiates, draw an arrow from where it start to where it stops. Please extend the arrow as far as the pain travels. Use the appropriate symbol(s) listed bel

NECK DISABILITY INDEX

This questionnaire will give your provider information about how your neck condition affects your everyday life. Please answer every section by circling the one statement that applies to you. If two or more statements in one section apply, please mark the one statement that most closely describes your problem.

Pain Intensity
Personal Care (Washing, Dressing etc.)
Sleeping
Lifting
Reading
Driving
Concentration
Recreation
Work
Headaches

BACK DISABILITY INDEX

This questionnaire will give your provider information about how your back condition affects your everyday life. Please answer every section by circling the one statement that applies to you. If two or more statements in one section apply, please mark the one statement that most closely describes your problem.

Pain Intensity
Personal Care
Sleeping
Lifting
Sitting
Traveling
Standing
Social Life
Walking
Changing degree of pain

TERMS OF ACCEPTANCE

When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective. 

Chiropractic has only one goal. It is important that each patient understand both the objective and the method utilized to achieve this goal. This will prevent any confusion or disappointment.

Adjustment: An adjustment is the specific application of forces to facilitate the body's correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine.

Health: A state of optimal physical, mental and social well-being, not merely the absence of pain, disease or infirmity.

Vertebral Subluxation: A misalignment of one or more of the 24 vertebrae in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body's innate ability to express its maximum health potential.

We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal evaluation, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area.

Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. Our only practice objective is to eliminate a major interference to the expression of the body's innate wisdom by correcting vertebral subluxations. Our only method is specific adjusting to correct vertebral subluxations.

All questions regarding the doctor's objectives pertaining to my care in this office have been answered to my complete satisfaction.

I therefore accept chiropractic care on this basis.


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 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 obligated to agree to those restrictions only to the extent they coincide with state and federal law.

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 effect 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. Our office may contact you periodically regarding appointments, treatments, products, services, or charitable work performed by our office. You may choose to opt-out of any marketing or fundraising communications at any time.

6. 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 who do not need them.

7. Patients have the right to file a formal complaint with our privacy official and the Secretary of HHS about any possible violations of these policies and procedures without retaliation by this office.

8. Our office reserves the right to make changes to this notice and to make the new notice provisions effective for all protected health information that it maintains. You will be provided with a new notice at your next visit following any change.

9. This notice is effective on the date stated below.

10. 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.

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

For further information regarding this notice, please contact our Doctor at 972-291-4455

Thank you for taking the time to fill out this form.

Monday  

8:00 am - 6:00 pm

Tuesday  

2:00 pm - 6:00 pm

Wednesday  

8:00 am - 6:00 pm

Thursday  

2:00 pm - 6:00 pm

Friday  

8:00 am - 12:00 pm

Saturday  

8:00 am - 12:00 pm

Sunday  

Closed

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