NEW PATIENT INTAKE FORM

OUR CLINIC PURPOSE:

TO HELP IMPROVE YOUR QUALITY OF LIFE!

Personal Wellness History

NEW PATIENT INTAKE FORM
If the Patient is a Minor, please fill out the Legal Guardian’s information below:
In Case Of Emergency (Name of relative or close friend not living in your home) :

YOUR HEALTH CONCERNS OR SYMPTOMS AND HOW THEY MAY AFFECT YOUR LIFE:

Thank you for taking the time to complete this form. The more we understand your current health status the better we will be able to guide you toward your ideal health goals.

Authorization to Use or Disclose Protected Health Information and Consent to Treatment

Your authorization is requested for purposes of delivering your care in an open-door environment as described in the office’s privacy notice.In the course of your care, in this environment, routine details of your condition and care may be disclosed to other patients or staff in the approximate vicinity of where your care is being delivered. We cannot assure that any of the details of your care will be addressed and considered as confidential by other patients.We are requesting your authorization in this regard to assure that you are fully informed and in agreement with the method and circumstances in which we deliver treatment. Your care will not be conditioned on your agreement to this authorization. You have the right not to sign this authorization and you also have the right to revoke this authorization at a later date if that is your wish. If you wish to revoke this authorization at some time in the future please advise us accordingly in writing. You always have the right to review our most updated PHI information. You can also contact our privacy officer at 512-480-9999.

Additionally, you are consenting to treatment by the above named provider(s). You understand that results are not guaranteed and are partly based on your cooperation with receiving the recommended care. You also will hold harmless, any complications of treatment, regardless of how rare complications may occur.We suggest you refer to: http://www.acatoday.org/Portals/60/Images/Infographics/risks_infographic.png . You also agree, you will discuss your care with our provider(s) and understand the treatment that will be rendered.In accordance with TBCE Rule 77.3, by my signature below, I choose to decline receipt of my clinical/billing summaries at every visit, but am aware that I can request them at any time.

Please sign below if you agree to this authorization and have reviewed our HIPAA privacy notice effective 9/13/2013.

Regarding Major Medical Insurance:

While our office firmly believes you should not entrust your health to an insurance carrier, as a courtesy to you we will bill services, which are deemed appropriate, to most major carriers on your behalf.

I, the patient and/or Guardian am aware that if I have insurance available it will be billed for services rendered, unless I request otherwise. It is expected that payments be made at the time of service unless other arrangements have been made. I am also aware that my insurance company may send me payments for services rendered by Minors Chiropractic/rehabFX which includes consultation, examinations, rehabilitation services, chiropractic, and Durable Medical Equipment.

I agree that when I receive any payments for these services, I will:

  1. Sign/Endorse the check and I WILL NOT DEPOSIT or CASH it.
  2. Under my signature, I will clearly and legibly print the following: “Make Payable only to rehabFX”
  3. I will enclose the check with accompanying letters or forms, such as the Explanation of Benefits (EOB), in an envelope and mail immediately to rehabFX, 4006 S. Lamar,Ste. 650,Austin, TX78704or bring to the office within 5 business days from receipt of the checks.

I understand that in the event that the check is not immediately sent to rehabFX, I will be responsible to pay the full and entire fee for all services rendered, plus any additional collection fees and legal costs related to collecting this debt.

By signing below you are stating you understand the conditions of receiving treatment at rehabFX and will comply with all the terms above or will be liable for all bills.

Please sign the attached Privacy Health Information Sheet: https://texasattorneygeneral.gov/files/agency/hb300_auth_form.pdf