new patient forms

Pecan Valley Chiropractic Center

Personal Information

Patient Name: _____________________________________________________ Today’s Date: _________________

Address:_________________________________________________________________________________________ Street Apt# City State Zip

DOB: ___________________ SS#: _______ - ______ - ________ Hm:_______________________
Email: www.______________________________________ Wk:______________________

Employer: ____________________________________ Occupation:____________________________________

Emergency Contact Name/ Relation: _________________________________________ Ph#:______________________

Patient Type (circle): Cash Ins Auto Other: ______________

Policy Holder Name: __________________________________________     DOB: ___________________

Secondary Insurance: _________________________________________   Policy#:______________________________
Policy Holder Name: __________________________________________   DOB: ___________________

Current Condition
Current Complaint: __________________________________________________________________________________
_________________________________________________________________________________________________
Is this a work injury? Y / N                  DOI: _________________             Accident Report Made w/ Employer:    Y /   N
Is this an auto accident?   Y   / N            DOA:_________________               Do you have PIP/ Medpay coverage? Y   /   N

How were you referred to our office? ____________________________________________________________________

(Please note: Anyone who refers someone to our office will receive a special “THANK YOU” gift package!)

I understand and agree that (regardless of my insurance status) I am ultimately responsible for the balance of my account for any professional services rendered. I have read all the information and have completed the above answers. I certify this information is true and correct to the best of my knowledge. I will notify you of any changes in my status on the above information.

Patient Signature Date

Please list all medications you are currently taking: __________________________________________________________
_________________________________________________________________________________________________
Please list any vitamins or supplements you are currently taking:________________________________________________
_________________________________________________________________________________________________

Medical History
Do you smoke? Y / N    If yes, how much? ____________ Do you chew tobacco Y / N If yes, how much?__________
Do you drink? Y / N         If yes, how much? _____________  Do you use recreational drugs? Y / N
*Are you pregnant or suspect you may be pregnant? Y / N   (Please mention to the receptionist & physician during exam)

Circle all that apply to you:
Allergies          Cancer         Hepatitis/ Liver Disease       Stomach Ulcers          Anemia                      Coronary Artery Disease   Heart Attack Stroke          Arthritis                             Diabetes                     High Blood Pressure Thyroid Disease
Asthma           Emphysema  High Cholesterol            Tuberculosis (TB)       Bronchitis               Gout
Seizure Disorder       Urinary Tract Infections

If you circled any of the above, please tell us about it: ________________________________________________________
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Please list all surgeries you’ve had & year performed: ________________________________________________________

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Circle all that apply to you. And yes, it is really important !

Chronic Fatigue       Constipation or loose stools        Depressed        Digestion Trouble or Reflux       Double Vision
Dry Eyes                  Easy Tearing                               Fast Heartbeat    Fibromyalgia                         Frequent Urination
Headache               Hearing Loss                              Incontinence       Lose Attention Before Finishing a Task
Sexual Dysfunction Trouble Swallowing                      Unconcerned w/ What’s Happening Around You
Very Compulsive    Very Forgetful                        Vision Loss

HIPAA Privacy Practices Acknowledgement

I have received the HIPAA Notice of Privacy Practices and/ or I have been provided an opportunity to review it. I understand that according to the HIPAA Privacy Act, the healthcare provider may disclose any information needed to complete billing and/ or treatment. Unless listed below, my medical information will be protected.

Name the people and/or organizations that you are authorizing to receive and use your protected health information
(For example: anyone changing or verifying any appointments, questions regarding treatment, etc):

                      Printed Name                                                            Relation

_____________________________________________           _____________________
                                Printed Name                                                            Relation

_____________________________________________           _____________________
                            Printed Name                                                               Relation

** May we use your name in our newsletters, advertisements, webpage ? Yes / No

_______________________________________ _________________

Print Patient Name Date

_______________________________________ _________________

Pecan Valley Chiropractic Financial Policy

Basic Policy: Payment is due at the time of service. I request payment of authorized services be made payable to Pecan Valley Chiropractic Center.

Payment Plans: By choosing one of the available payment options offered during the Report of Findings, I understand that I must adhere to the required payment dates until services are paid in full. Special arrangements may be made by Pecan Valley Chiropractic Center.

Patients With Insurance/ Medicare: We bill most insurance carriers and Medicare for you when proper paperwork is provided to us. Co-payments and deductibles are due at the time of service. If an insurance carrier has not paid within 60 days of billing, or denies payment, all professional fees are due and payable in full from you unless special arrangements have been made with Pecan Valley Chiropractic Center.

Accident Cases: You must present Personal Injury Protection (PIP) or Medpay from your auto insurance or a Letter of Protection (LOP) from your attorney for any accidents. This must be presented on the initial visit unless special arrangements are made with Pecan Valley Chiropractic Center. We do not accept any third-party payors unless direct payment to Pecan Valley Chiropractic Center is agreed upon in writing prior to treatment.

Non-Covered Services: Any care not paid for by your existing insurance coverage will require payment in full. Payment arrangements will be made by Pecan Valley Chiropractic Center upon notice of insurance claim denial.

Missed Appointments: In fairness to other patients and the doctors, if you are unable to make your appointment, please give our office 4 hours notice to reschedule or cancel an appointment. Emergencies and work schedules are understandable. You may be charged $25.00 for consecutive no-show appointments.

Assignment of Benefits: I hereby assign all medical payments to Pecan Valley Chiropractic Center for services rendered. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said payor. I hereby authorize said assignee to release all information necessary to secure payment.

I have read and agree to the above financial policy and understand that I am ultimately responsible for any unpaid balances.

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Print Patient Name                                                        Date

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Patient Signature

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Print Parent/ Guardian Name                                             Date