Chiropractic Patient Update Form printable pdf download

CHIROPRACTIC PATIENT UPDATE

Please complete Parts A & C in all cases. Part B should be completed only if the information has

changed since you were last in our office.

Thank You!

PART A

Name:

Phone:

E-mail address:

Fax #

Cell Phone

Address:

Purpose of this appointment:

Is this the same problem you were originally under care for?

( ) Yes

( ) No

If yes, are there any additional symptoms?

Other doctors seen for this condition:

What medications or drugs are you taking?

PART B

Occupation:

Employer:

Employer's address:

Work Phone:

Spouse:

Spouse's Employer:

PART C

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. I understand that interest is charged on overdue accounts at the annual

rate.

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.

Date Signed:

Signature:

Health Insurance Coverage

( ) Yes

( ) No

Company:

Chiropractic Patient Update

Chiropractic Patient Update Form

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