Home Phone Work Cell

Dr. Jerrid Goebel Licensed Acupuncturist 824 1st _Street

Dr. Stuart Johnson Sturgis, South Dakota, 57785

Dr. Al Gunderson Telephone (605) 347-4003

Todays date: ______________

Patient’s Name

___________________________________

Date of Birth

_______________ age____

Address

_________________________________

City

________________

State

____________ Zip___________

Soc. Sec.

#

Gender:

M / F

Marital Status

: M / S / D / W

Spouse’s or Parent’s Name

___________________________

Preferred Language

__________________ White Asian Hispanic

Race: American Indian or Alaska Native Black or African American

Hawaiian/Other Pacific Island

Home Phone ____________ Work ______________ Cell_____________ Email __________________

Referred By: Yellow Pages____ Doctor_ _____ ___ Other_ _____ ___

Newspaper____ Friend_ _____ ___ Radio____ Family_ _____ ___

Occupation__________________________ Employer_______________________________________

Insurance Company

Insured Name

(if not patient)______________

(We will photocopy insurance card)

Insured date of birth

_____________________

What is the main reason for visiting our office today? _________________________________________

How long have you had this condition? _____________________ Date of Incident ____/____/_____

Work Related? _____________ Auto Accident? ____________ Other Type of Accident? ____________

Have you had this or similar conditions in the past? __________________________________________

(If so, please explain)

Is this condition interfering with: Work ____ Sleep ____ Daily Routine ____ Other____________________

Other doctors or therapists who have treated THIS Condition: ___________________________________

Has this condition: Improved _____________ Unchanged _____________ Worsened _____________

Family Physician: Name__________________________ Date of Last Wellness Exam: ____/____/_____

Do you have a Pacemaker? YES NO Recent Surgeries/Dates: ______________________________

Current Height _____ Weight _____ lost or gained weight? __________ b/p

(staff will check)

_____ / ____

Smoking status- Never ___ Former ____ Current some day ___ Current every day___

Current Medications:

(

we will make a copy if a list is available)

Check any of the boxes that apply to you, CURRENT or PAST.



Ear Ringing



Earache



Runny Nose



Sinus Congestion



Sore Throat



Allergies



Difficulty Breathing



Asthma



Constipation



Diarrhea



Heartburn/

Indigestion



Abdominal Pain



Menstrual Cramps



Bladder Trouble



Urinary Trouble



Tension Headache



Migraine



Stiff Neck



Neck Soreness



Cancer



Depression



Anemia



Diabetes



Muscle Pain



Muscle weakness



Muscle Cramps



Muscle Twitching



Joint Stiffness



Joint Pain



Thyroid Condition



Angina



Heart Murmur



Heart Palpitation



Stroke



Hypertension



Seizures



Vertigo



Dizziness



Hand Trembling



Loss of Sensation



Uncoordinated



Weak Grip



Facial Paralysis



Difficulty with Speech



Loss of Memory



Numbness



Tingling



Heat Intolerance



Cold Intolerance



Hair Changes



Breast Changes

Any other comments? ______________________________________________________________

Mental Work Heavy

Moderate

Light Hours per day __________

Physical Work Heavy

Moderate

Light Hours per day __________

Exercise Heavy

Moderate

Light Hours per week ____ Type __________

Alcohol

Beer/ Week_____ Liquor/ Week _____ Wine/ Week_____

No. of Years_____

Caffeine

Cups/ Day _____

No. of Years _____

Aspirin

No./ Day _____

No. of Years _____

Place an X on the line where it applies:

How bad are the symptoms now?

Mild

Severe

How bad were the symptoms in the past?

Mild

Severe

ACKNOWLEDGEMENT OF NOTICE

OF HIPAA

You May Refuse to Sign This Acknowledgement*

I have been offered/ received a copy of this office’s Notice of Privacy Practices.

___________________________________________ ______________________________________ ____________

Please Print Name Signature Date

We attempted to obtain written acknowledgement of our Notice Of Privacy Practices, but acknowledgement could not be obtained because:  Individual refused to sign

 Communications barriers prohibited obtaining the acknowledgement  An emergency situation prevented us from obtaining acknowledgement

 Other (Please Specify): ______________________________________________________________________

INSURANCE

I, __________________________, herby acknowledge that my insurance plan my not pay for all charges

incurred in this office, such as exams, x-rays, heel lifts, or my Deductible. I acknowledge that I am

responsible for any charges refused or not covered by my insurance company. Further, I will pay for my

collections or legal charges incurred in the collection of these uncovered charges should I fail to pay them

during the agreed upon time. I hereby authorize the doctor to release all information necessary to secure the

payments of benefits. I authorize the use of my signature on all my insurance submissions whether manual or

electronic.

__________________________________________ Date______________

Signature of insured/ guardian

MEDICARE AUTHORIZATION

I request the payment of authorized Medicare benefits be made either to me or on my behalf to Sturgis

Chiropractic, P.C. for any services furnished to me by the physician. I authorize any holder of medical

information about me to be released to the Health Care Financing Administration and its agents any

information needed to determine these benefits or the benefits payable for related services. I understand my

signature requests that payments be made and authorizes release of medical information necessary to pay the

claim. If “other insurance” is indicated on item nine of the HCFA- 1500 form or elsewhere on other approved

forms or electronically submitted claims, my signature authorized release of the information to the insurer or

agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge of

determination of the Medicare carrier as the full charge, and the PATIENT IS RESPONSIBLE FOR ANY NON-

COVERED CHARGES SUCH AS X-RAYS, EXAMS, COINSURANCE, AND/ OR DEDUCTIBLE. Coinsurance

and the deductible are based upon the charge determination of the Medicare carrier.

Financial/Office Policy

HEALTH INSURANCE

Please realize that your health insurance is your insurance, not ours. We will do everything possible to help you get reimbursed from your insurance carrier, but the ultimate obligation for payment rests with you, the patient, not with the insurance company. Co-pay is expected at the time of service. If your insurance deductible for the year has not been

met at the time of service, payment is expected in full on that day of service.

OFFICE VISITS

For office visits, treatment, x-rays, or supplies, please pay at the time of service. We gladly accept cash, check, MasterCard and Visa

.

CASH

If you are a cash patient, payment is expected at time of service. We gladly accept cash, check, MasterCard and Visa.

MEDICARE

We will file directly with Medicare and/or your supplemental insurance for you, but you are responsible for the charges that Medicare or your supplement does not cover or pay. If your Medicare deductible for the year has not been met and your

supplement does not cover it, payment is expected in full on that day of service.

MEDICAID

You must have a current Medicaid monthly eligibility card and bring it to each visit. Cost-Share portion is expected at

the time of service.

WORKMAN’S COMPENSATION / MVA

If you are here because of a work related injury / MVA, we must verify the coverage of your medical bills from your employer and / or your MVA carrier, we need exact information from you on the time, location and nature of your injury.

Please bring this information with you and notify the receptionist that you are covered under worker’s compensation or automobile insurance. If for some reason the worker’s compensation or MVA information is not verified, then you,

the patient, are responsible for the charges.

UNPAID BILLS

If the account must be turned over to collection, all costs and fees associated with such collections are the responsibility of the patient. Once accounts are turned over for collection, payments are due to collection agency.

Consent To Treat Patient Name:_________________________________

To the patient: Please read this entire document prior to signing it. It is important that you understand the information contained in this document. Please ask questions before you sign, if there is anything that is unclear.

Acknowledgement

I acknowledge by my signature below that my Doctor of Chiropractic has discussed the proposed treatment with me and any material risks and expected benefits of that treatment. I have been given the opportunity to ask questions and any questions I had have been answered to my satisfaction.

The nature of the chiropractic adjustment

The primary treatment used by a Doctor of Chiropractic is spinal manipulative therapy which will be used to treat you. Your chiropractor may use their hands or mechanical instrument(s) upon your body in such a way as to move your joints. That may cause an audible “pop” or “click”, much as you have experienced when you “crack” your knuckles. You may feel a sense of movement.

Analysis/Examination/Treatment

As a part of the analysis, examination, and treatment, I am aware and consent to the following procedures which may be used in my chiropractic care: Spinal Manipulative Therapy, Range of Motion Testing, Muscle Strength Testing,

ultrasound, radiographic studies, basic neurological testing, palpation, orthopedic testing, postural analysis, hot/cold therapy, electrical stimulation, vital signs.

The material risks inherent with chiropractic adjustments

As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation and therapy. These complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, cervical myelopathy, costovertebral strains and separations, and burns. Some patients will feel some stiffness and soreness following the first few days of treatment. We will make every reasonable effort during the examination to screen for contraindications to care; however, if you have a condition that would otherwise not come to our attention, it is your responsibility to inform us.

The probability of those risks occurring

Fractures are rare occurrences and generally result from some underlying weakness of the bone which we check for during the taking of your history and during examination and X-ray.

The availability and nature of other treatment options

Other treatment options for your condition may include: Self-administered, over-the-counter analgesics and rest

Medical care and prescription drugs such as anti-inflammatory, muscle relaxants and pain killers Hospitalization

Surgery

If you choose to use one of the above noted “other treatment” options, you should be aware that there are risks and benefits of each such option and you should discuss these with you primary care physician.

The risks and dangers to remaining untreated

Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed.

DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE.

By signing below, I state that I have weighed the risks involved in undergoing treatment and have decided that it is in my best interest to undergo the recommended treatment. Having been informed of the risks, I hereby give my consent to that treatment.

Dated:_________ Dated:_____________

________________________ __________________________ Patient’s Name (printed) Doctor’s Name (printed)

________________________ __________________________

Signature Signature

________________________