Patient Health Information Consent Form

We want you to know how your patient health information 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 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 the requested information to the health

insurance company provided to us by the patient for purposes of payment. Be

assured that this office will limit the release of all information 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 if

disclosures have been made and submit in writing any further restrictions on the

use of their information. Our office is not obligated to agree on those restrictions.

3. A patient’s written consent need only be obtained one time for all subsequent

care given in this office unless records are requested by an outside source. For

example; Law Firm.

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 have 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 designate 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.

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.

I have read and understand how my patient health information will be used and I

agree to these policies and procedures.

Name of Patient: ___________________________________________

Signature of Patient: ________________________________________

Date: _________________

Financial Agreement

For the calendar year dated _______, your Insurance benefits are as described below. After your insurance benefits become

exhausted (visit limit reached), the follow will occur: Cash basis treatment. This means that you, the patient will be

responsible to pay the amount agreed below at each treatment with Dr. Dawn Cute until your Insurance benefits restart the

next benefit period.

Your Insurance will pay for ______ visits. Your copay while your insurance benefits are NOT exhausted will be $________ per

visit. Once your Insurance exhausts it benefits for Chiropractic you will be responsible to pay $________ per visit.

I________________________________________ agree to the above and will adhere to the agreement above.

Signature: _____________________________________ Date: ______________________

Advanced Beneficiary Notice of Non Coverage (ABN)

**Medicare Only**

Note: If Medicare doesn’t pay for item(s) or Service(s) below, you may have to pay. Medicare does not pay for everything,

even some care that you or our health care provider have good reason to think you need. We expect Medicare may not pay

for the item or service below.

Item/Service Reason Medicare may not pay: Estimated Cost for you:

Chiropractic Spinal Adjustments and Examinations

Medicare reviews each case and may deny some adjustments as “maintenance” or “wellness “care and may deny for medical necessity or deny if # of visits exceed what they specify your need is for Chiropractic.

$_________ per visit

Chiropractic X-rays Medicare does not cover these services when prescribed by a Chiropractor. You will need to take the script to your General Practitioner and ask them for a referral for these X-rays. Please refer to the notice on the script.

Medicare may bill you for these X-Rays if you did not obtain a referral from your General Practitioner.

Chiropractic Therapy Medicare does not cover these items. Other Insurance may cover these.

Combined with amount above for Chiropractic Spinal Adjustments and Exams.

Please chose one of the Following:

______ Please do not bill Medicare. I will pay for the above services out of pocket at the amount listed above.

______ Please bill Medicare. I understand that if Medicare does not pay I will be billed for these services.

Signing below means that you have received and understand this notice. You also may request a copy.

Signature: _________________________________________________ Date: _________________________

Optimum Health Chiropractic

8945 Ridge Avenue Suite 2 & 7

Philadelphia, PA 19128

215-508-3291 (P)

215-508-3022 (F)

Optimumhealthchiropractic@outlook.com

Confidential Health Information

Please allow our staff to photocopy your driver’s license and insurance card. All

information you supply is confidential. We comply with all federal privacy standards.

Please print clearly and answer to the best of your knowledge.

Today’s date: _______________ Who May We Thank for Referring you? ________________________________

Name: ________________________________ Date of Birth: ________________ Age: _____________ Gender: ___________

Social Security #: ___________________ Address: _____________________________________________________________

Marital Status: ___________________ Smoking Status: _________________ If quit, when? _______________________

Height: ______________ Weight: _________ Blood Pressure: _______________ Pacemaker? _______________________

Email Address: _____________________________________________ Occupation: __________________________________

Home Phone #: ____________________ Cell Phone #: _________________ Work Phone #: ______________________

Name of Emergency Contact: ______________________Relationship to Patient: ________________ Phone #: ______________

Have you consulted a Chiropractor before? _______ if yes, when? __________ If so, whom? ____________________________

Primary Care Provider’s Name: _____________________ Phone #: ___________________ Date of Last Physical: ____________

Insurance Carrier: ___________________________ Policy #: _________________Who carries this policy? _________________

Insured’s First & Last name: _____________________________Date of Birth of Insured: ______________________________

Spouse Name: ____________________________________________ Health status: __________________________________

Children’s Names & Ages: ________________________________________________________________________________

Have you had any X-Rays Taken: _____________________________________________ How long ago? _________________

Please list any surgeries you have had: ______________________________________________________________________

Any slip and falls, injuries or car accidents? __________________________________________________________________

_____________________________________________________________________________________________________

Please list any Medication/ Vitamins and Herbal Supplements you are currently taking: ______________________________

_____________________________________________________________________________________________________

Any Known Allergies? ___________________________________________________________________________________

Do you Exercise? ______ If so, how often per week? ______ Caffeine Intake? ___________ How many drinks daily? _________

Are you pregnant? ____________________ Any possibility you may be? _______________

Appointment Scheduling: We ask that you try your best to stick with the Doctor’s recommendation for care. Putting a lot of

space in between visits will cause you to regress in care or not heal as quick as possible. We understand that your schedule may

change but please always try to reschedule right away when having to cancel an appointment. Rescheduling appointments may

also cause your reexaminations to be pushed back to later dates which could affect your treatment plan.

Please sign here as acknowledgement of this statement and to agree to your participation in this benefit:

Signature: ________________________________________________________ Date: __________________

Family History

Some health issues are hereditary. Tell Dr. Cute about the health of your immediate family members.

Relative Age State of Health

Illnesses Age at Death

Cause of Death

Father

Mother

Sister 1

Sister2

Brother 1

Brother 2

Social History

Circle one: daily or weekly

Alcohol Use Daily Weekly How Much?

Coffee Use Daily Weekly How Much?

Tobacco Use Daily Weekly How Much?

Exercising Daily Weekly How Much?

Pain Relievers Daily Weekly How Much?

Soft Drinks Daily Weekly How Much?

Water Intake Daily Weekly How Much?

Primary Complaint

The Primary symptom that prompted me to seek care today is: ____________________________________________________

Was this a result of a Work Injury or Motor Vehicle Accident? ______________________________________________________

When did you first notice your current symptoms? ________________________________________________________________

What have you done to relieve these symptoms? ________________________________________________________________

Activities of Daily Living

Fill in or check off column which fits your ability to function with each activity

Activity No Effect Mild Moderate Severe

SITTING

RISING OUT OF A CHAIR

STANDING

WALKING

LYING DOWN

BENDING OVER

CLIMBING STAIRS

USING A COMPUTER

GETTING IN/OUT OF A CAR

DRIVING A CAR

LOOKING OVER SHOULDER

CARING FOR FAMILY

GROCERY SHOPPING

HOUSEHOLD CHORES

LIFTING OBJECTS

REACHING OVERHEAD

SHOWERING OR BATHING

DRESSING MYSELF

LOVING LIFE

GETTING TO SLEEP

STAYING ASLEEP

CONCENTRATING

EXERCISING

YARD WORK

Is this pain radiating? ________________

If So, to What other part of the body? __________________________________________

Please mark on the body where you are currently having pain. Please also

note what type of pain/ ache you are having. For example: Ache, Numbness,

Pins & Needles, Burning, Stabbing, or Throbbing.

Musculoskeletal

*Check box which fits you.

Have Had Have Had

Osteoporosis

Knee Injuries

Anxiety

High Blood

Pressure

Asthma

Anorexia/Bulimia

Blurred Vision

Alcoholism

Arthritis

Foot/Ankle Pain

Depression

Low Blood

Pressure

Apnea

Ulcer

Ringing in ears

Psoriasis

Scoliosis

Shoulder

Problems

Headaches

High Cholesterol

Emphysema

Food Sensitivities

Hearing Loss

Eczema

Neck Pain

Elbow/Wrist pain

Stroke

Poor Circulation

Hay Fever

Heart Burn

Chronic Ear

Infections

Hepatitis

Measles

TMJ

Scarlet Fever

Angina

Shortness of Breath

Constipation

Loss of Smell

Hair Loss

Hip Disorders

Numbness

Excessive Bruising

Pneumonia

Loss of Taste

AIDS

Cancer

Thyroid Disorder

Chicken Pox

Fainting

Immune Disorders

Infertility

Diabetes

Hypoglycemia

Bedwetting

Poor Appetite

Frequent Infections

Prostate Issues

Epilepsy

Goiter

Gout

Heart Disease

Sudden Weight Loss

Sudden Weight Gain

Low Energy

Multiple Sclerosis

Weakness

Arteriosclerosis

Malaria

Rheumatic Fever

Polio

Tuberculosis