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Elevated Health Center Adult Intake
PERSONAL INFORMATION
First Name
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Middle Initial
Last Name
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Birth Date
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Age
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Sex:
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Male
Female
Address:
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City
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Zip Code;
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State:
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Cell Phone Number:
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Emergency Contact/Relationship
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Emergency Contact Phone Number
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Text Reminders ?
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Yes, Please!
No, Thanks.
Cell Provider:
AT&T
Boost Mobile
Cingular/AT&T
Comcast/Xfinity
Cricket
Nextel
Sprint
T-Mobile
Verizon
Virgin Mobile
Other
Email Address:
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Who can we thank for referring you or how did you hear about Elevated?
Occupation:
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Employer's Name:
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Is this an AUTO or Worker's Compensation Injury?
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Yes
No
If YES, please explain the details of the injury.
Insurance? Please provide front and back images of your health insurance AND a photo ID for verification purposes.
REASON FOR SEEKING CARE
What is your reason for seeking care at Elevated Health Center?
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When did this begin? (If applicable)
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Are there any major injuries and/or surgeries we should know about?
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What is this affecting that is MOST important in your life? (List all that apply)
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Have you seen any other providers for this condition? (List all that apply)
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Have you seen a chiropractor before?
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Yes
No
How long ago?
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Clinic/Doctor Name:
Reason for change? (If applicable)
What health goal, if you were to complete or accomplish it, would have the greatest impact on your life?
HEALTH CONCERNS
Select any concerns that apply to you:
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Anxiety/Depression
Arthritis
Cold hands/Feet
Diabetes
Digestive Troubles
Dizziness
Fatigue/Sleep Issues
Headaches
Hypertension
Irritability
Loss of Balance
Loss of Concentration
Memory Problems
Nausea/Vomiting
Neck/Back Pain
Pain in Arms/Legs
Ringing in Ears
Sensitivity to Light
Sinus Troubles/Allergies
Stiffness/Flexibility
N/A
Other:
Vitamins/Supplements
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Multi-Vitamin
Vitamin D3
Fish Oil/Omega 3
Probiotics
Other:
N/A
Check any medications being used:
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Anxiety/Depression
Blood Pressure
Pain Narcotics
Muscle Relaxants
Migraine/Headache
Cholesterol
ADD/ADHD
Diabetes
Other:
N/A
Explain any boxes checked above or add additional concerns:
STRESS QUESTIONNAIRE
Physical Stress
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Physical Pain
Low Energy/Fatigue
Job/Hobbies Cause Discomfort
Tightness/Stiffness
History of Accidents/injuries
Inability to Exercise/Perform Physical Activities
N/A
Other
Other
Chemical Stress:
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Fast Food/Highly Processed Food
Medications (Prescription or OTC)
Consume Alcohol
Tobacco
Amalgam Fillings
Makeup/Lotion/Other Skins Products
N/A
Other
Other
Emotional Stress
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Work/Job
School
Health
Finances
Family
Daily Schedule/Time
N/A
Other
Other
What else about your health or your life do you feel is important for the doctor to know?
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PATIENT HIPAA CONSENT FORM
Protecting the privacy of your personal health information is important to us. Disclosure of your protected health information without authorization is strictly limited to define situations that include emergency care, quality assurance activities, public health, research, and law enforcement activities. Any other disclosures for the purposes of treatment, payment, or practice operations will be made only after obtaining your consent. You may request restrictions on your disclosures. You may inspect and receive copies of your records within 30 days with a request. You may request to view charges to your records. In the future, we may contact you for appointment reminders, announcements, and to inform you about our practice and its staff. I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: conduct, plan, and direct my treatment and follow up with multiple healthcare providers who may be involved in that treatment directly or indirectly, obtain payment from third party payers, and conduct normal healthcare operations such as quality assessments and physician's certificates. I have read and understand your Notice of Privacy Practices. I also understand that I can request in writing that you restrict how my personal information is used and disclosed.
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Client Name
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Date:
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FINANCIAL POLICY
Our goal is to provide the highest quality of healthcare possible for our patients. In order to achieve this goal, we need your commitment as well.
- We urge our patients to follow the doctors' recommendations for care.
Please keep your appointments as
scheduled or call our office within 24 hours to make any changes
. In order to attain the level of
achievement we both desire, care must be followed.
- I authorize Elevated Health Center to release any information deemed appropriate concerning my physical
condition to any insurance company, attorney, or adjuster in order to process any claim for reimbursement
for charges incurred by me.
- Chiropractic care in this office deals with vertebral subluxation, and may be therefore be billed under the
S8990 adjustment code. While we will provide an itemized receipt upon your request, we anticipate that care
billed under this code will not be reimbursed by a third party carrier. This does not apply to PI, Worker's
Compensation Insurance, or Medicare. HSA and FLEX spending accounts may be utilized.
- I authorize the direct payment to Elevated Health Center of any sum I now or hereafter owe by my attorney
out of settlement of my case, and by any insurance company obligated to make payment to me or Elevated
Health Center based in whole or in part upon the charges made for services received. I hereby appoint Elevated
Health Center authority to endorse and cash checks, drafts, or money orders made payable to the undersigned
or as co-payee with this clinic or payments due for services rendered on behalf of the undersigned by Elevated
Health Center.
- If you have any questions about our financial policies, please ask our staff. If you need to make special
arrangements, please ask. We will do everything possible to meet your financial needs.
- High Deductibles: With the recent health care changes, high deductible plans are more common place. As a
result, charges for chiropractic care offered at Elevated Health Center will be collected in full at the time of
visit, based on the contracted amounts with each insurance company.
This high deductible balance will not
be
allowed to exceed $100.00
. If the balance is not paid in full within 30 days, any outstanding balance will
accrue interest at a rate of 1.75% per month (21% annually). Failure to settle a balance for more than 90 days
may result in the patient account being turned over to a collections agency.
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Client Name
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Date:
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AUTHORIZATION FOR CARE
At Elevated Health Center, we do not diagnose or treat any disease or condition other than vertebral subluxation and the doctors/clinic will not be held responsible for any pre-existing medical conditions. I certify that the above information is correct to the best of my knowledge. I will not hold the doctors or any staff member of Elevated Health Center responsible for any errors or omissions that I may have made in the completion of this form. Chiropractic, as well as all other types of health care is associated with potential risks in the delivery of treatment. While chiropractic treatment is remarkably safe, you need to be informed about the potential risks related to your care to allow you to be fully informed before consenting to treatment. Please inquire if you have further questions. Chiropractic is a system of health care delivery and therefore, as with any health care delivery system, we cannot promise a cure for any symptom, condition, or disease as a result of treatment in this office. An attempt to provide you with the very best care is our goal, and if the results are not acceptable, we will refer you to another provider who we feel can further assist you. I hereby authorize the doctors and staff at Elevated Health Center to treat my condition as deemed appropriate.
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Client Name
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Date:
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ADVANCED BENEFICIARY NOTICE (ABN)
The purpose of this section is to help you be aware of chiropractic services in this office as it relates to any medical insurance you may have. Chiropractic care in this office is not focused on diagnosis of or relief of symptoms; it is centered on the location, analysis, and correction of underlying vertebral subluxations. Because of this, most services are coded in a manner which insurance carriers view as maintenance or wellness care and most likely will not be covered. Signing below signifies that you want the services provided in this office, but understand that not all the care is covered by your insurance company and therefore, not billed to them. Therefore, you are responsible for payment and cannot appeal to your insurance carrier as they do not meet the criteria laid out by your insurance company. This notice gives our opinion and policies as it relates to insurance coverage, not an official Medicare or other insurance carrier's stance or decision. Signing below indicates you have receive and understand this notice.
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Client Name
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WORKER'S COMPENSATION POLICY
If you were involved in a worker's compensation injury, we will bill the worker's compensation insurance to help cover the treatment charges incurred in our office.
Attorney Liens:
If you hire an attorney to represent you in a lawsuit for coverage in a Worker's Compensation claim. It is our policy to have your attorney sign a Doctor's Lien. This will guarantee direct payment to our office for any unpaid balance upon the settlement of your suit. We retain the right to first submit all charges to your private and/or auto insurance policy for payment. Further,
this office does not discount or reduce the amount of your balance based upon the outcome of your settlement.
Responsibility for Payment
: As a courtesy to you, we will gladly submit your charges to your insurance company(ies) and/or your attorney; however, all services rendered by this office are charged directly to you, and ultimately,
you are personally responsible for payment of these charges, regardless of any insurance reimbursement or settlement you may or may not receive.
If, at any time, you have further questions about your care, please do not hesitate to ask. I have read and agree to the above.
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Client Name:
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CANCELLATION POLICY
Here at EHC, we have a strict 24-hour notice cancellation policy. You may cancel your appointment anytime 24 hours or more before the appointment without a charge. Unless it is an emergency,
if a client does not show up OR call to cancel a scheduled appointment, the client will be charged $50.00 for the scheduled visit.
We understand sometimes life can throw us unexpected emergencies and these unanticipated things are not always within our control. Thank you for your understanding and we look forward to helping you elevate your health! I have read the above statement and agree to the above terms.
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