Improving Lives & Performance
Dr. Jeff Eidsvig, D.C., TPI-‐CGFI
3060 Communications Parkway, Suite #104
Plano, Texas 75093
972-‐312-‐9310
New Patient Information / Change of Information
Date: _________________________________________
New Patient _____ Change of Info _____
Patient Name: ____________________________________________________________ Age: ______________________
Date of Birth: _________________________________ Gender (circle one): MALE FEMALE
SSN#: __________________________________ E-‐Mail: _________________________________________________________
Address: ___________________________________________ City/State/Zip: _____________________________________
Cell Ph#: ________________________ Home Ph#: ________________________ Work Ph#: ______________________
Emergency Contact: __________________________________________________ Ph#: ______________________________
Referred By: _________________________________________ Internet (Search Engine): ______________________
Primary Care Physician: _____________________________________________ Ph#: ______________________________
Relationship Status (circle one): MARRIED SINGLE DIVORCED WIDOWED
Patient Insurance Information
Policy Holders Name: _____________________________________________ Date of Birth: ______________________
Relationship to Policy Holder (circle one): SELF SPOUSE CHILD OTHER:____________
Primary Insurance Company: ___________________________________ Employer: __________________________
Insurance Type (circle one): PPO POS HMO
Subscriber ID#: ___________________________________________ Group #: ____________________________________
Secondary Insurance Company: _________________________________ Employer: _________________________
Insurance Type (circle one): PPO POS HMO
Subscriber ID#: ___________________________________________ Group #: ____________________________________
Authorization To Release Information:
I hereby authorize the above named agency to release any/all treatment information requested by attorneys, physicians, insurance companies, employers, health care providers or any other entity which may be concerned with the payment of charges incurred for thetreatment of services of Dr. Jeff Eidsvig, D.C., PLLC and authorize payment directly to Dr. Jeff Eidsvig, D.C., PLLC for services rendered. I accept responsibility for payment of any charges not paid or accepted by my
insurance carrier.
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Willow Bend Sports & Spine Center
Patient Intake Form
1. What is the “main” reason for your visit? __________________________________________________________
4. Use the diagram and symbols below to show where you are currently experiencing your
main complaint today:
PAIN DRAWING ASSESSMENT
Draw the location of your pain on the body outlines using the appropriate symbol. Include all affected areas. Mark the severity of your pain at the bottom of the page.
ACHE BURNING NUMBNESS PINS & NEEDLES STABBING
ZZZ BBB XXX = = = //// ZZZ BBB XXX = = = ////
NO PAIN 1 2 3 4 5 6 7 8 9 10 INTOLERABLE PAIN
CIRCLE YOUR PAIN ESTIMATE
I understand and agree that health and accident Insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that the doctor’s office will prepare any necessary reports and forms to assist me in making collection from the insurance carrier, and that any amount authorized to be paid to the doctor’s office will be credited to my account on receipt. However, I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care at this office, any outstanding charges for professional services rendered me will be immediately due and payable.
Patient’s Signature_________________________________SS#____________________________Date______________
Guardian or Spouse’s Signature Authorizing Care ___________________________________Patient #_______________
Name: ________________________________________________
Date: _________________________________
Date of Birth: _______________________________________
Contact PH#: _______________________
2. On the scale below, please indicate the severity of your main complaint (circle one)
(None) 0 1 2 3 4 5 6 7 8 9 (Severe)
3. Please indicate the overall improvement of your condition since your initial visit
No Change 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
A = Aching
B = Burning
C = Cramping
D = Dull
N = Numbness
S = Sharpness
P = Pins/Needles ST= Stabbing
^^^ = Shooting
/// = Throbbing
+++ = Tingling
T = Tightness
O = Other:_______________________________
Patient History
Patient Medications: (Please include Vitamins, Herbs, or Supplements)
_____________________________
___________________________
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___________________________
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Past Medical Conditions/Hospitalizations/Surgeries
_____________________________
___________________________
_____________________________
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Patient Allergies: (Please list ALL food and medicine allergies)
_____________________________
___________________________
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Patient Family History: (Please list any medical conditions)
Father:
____________________________________
Mother: ___________________________________________Brother(s):
________________________________
Sister(s): _________________________________________Grandmother(s):
__________________________
Grandfather(s): _________________________________Information Regarding Current Symptoms and Past Care: (Please circle)
Does the pain wake you up at night? Yes No
Does the pain radiate from one region to another? Yes No
Do you have noticeable weakness in any region? Yes No
Do you have any bladder issues as a result of your condition? Yes No
Have you had an MRI, X-‐Ray, CT Scan, or Bone Scan for your condition(s)
within the past year? Yes No
Please indicate when and which Imaging Facility: _____________________________________________________
Social History
Patient Occupation (Describe Environment): ____________________________________________________________ Alcohol: Yes No If yes, I have _____ drink(s) per day or _____ drink(s) per month. Tobacco: Yes No If yes, I smoke _____ pack(s) per day or _____ pack(s) per week. Illegal Drugs: Yes No If yes, what substance: ______________________________________________ Work History (circle one): Employed Unemployed Retired Homemaker Student Other Relationship Status (circle one): Single Married Divorced Widow
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Willow Bend Sports & Spine Center
Treatment for Consent / HIPPA Form
First Name: ___________________________________________ Last Name: ______________________________________________
My preferred method of communication regarding my medical conditions is indicated below:
_____ Cell Ph#: __________________________________ _____ Home Ph#: _____________________________________
_____ E-‐Mail: ____________________________________
If the above method is by phone, please check the appropriate box below (check one):
_____ Leave a message with detailed information _____ Leave a message with call back number only
Please note you are responsible for any charges incurred in receiving our communications.
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Signature of Patient/Legal Guardian Date
Insurance Authorization:
I hereby authorize the release of medical or other information to myinsurance company (via fax or e-‐mail) concerning charges/treatments provided to me by the doctor(s) listed. I hereby assign benefits and understand payment is due at the time services are rendered including my deductible, co-‐payment, co-‐insurance, or any other balances not paid by my insurance carrier (excluding contractual allowances) at the time of service. If, after 60 days, insurance payment has not been received, I understand all charges are my responsibility and payable immediately. Additionally, I understand I am responsible for providing the referral from my primary care physician. In the even such a referral has not been provided to the doctor(s) at Willow Bend Sports & Spine Center, I agree to pay for the service(s) at the time they are rendered.
Consent For Treatment:
I hereby authorize the doctor(s) at Willow Bend Sports & Spine Center and their staff to perform diagnostic tests and provide the necessary treatment for Chiropractic/Medical evaluation and health care for the above-‐mentioned patient.Patient Privacy Practices:
I understand my rights regarding my protected health information governed by the Health Insurance Portability and Accountability Act of 1996 (HIPPA). I have been informed of, and given the opportunity to, review and secure a copy of Willow Bend Sports & Spine Centers’ Notice of Privacy Practices, which contain a complete description of the uses and disclosures of my protected healthinformation. I understand the Notice of Privacy Information serve as: 1. A basis for planning my care and treatment.
2. A means of communication amongst health care professionals who contribute to my care. 3. A source of information for applying diagnosis and surgical information to my bill. 4. A means by which a third-‐party payer can verify services billed were actually provided.
5. A tool for routine health care operations, such as assessing care quality and reviewing the competence of health care professionals.
I have read and understand the Patient Privacy Practices provided by Willow Bend Sports & Spine Center. I understand my personal health information will be used in treatment, payment, and operations, including those activities performed in order to improve the quality of care. I acknowledge receipt of this information and give authorization for the release of my “Medical Records/Privacy Information” to the following:
I Authorize my Medical Records/Privacy Information to be Discussed/Disclosed to:
Patient: ________________________________________________________________ PH#: ________________________________
Contact Name: ________________________________________________________ PH#: ________________________________
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Willow Bend Sports & Spine Center
Insurance/ Financial Information and Policies
First Name: ___________________________________________ Last Name: ______________________________________________
Financial Policies: Dr. Jeff Eidsvig, D.C., PLLC appreciates your confidence in choosing WBSSC to provide your health care needs. Our services imply a financial responsibility and obligation on your part to ensure full payment of our fees. WBSSC is committed to providing the best treatment possible for our patients and our fees reflect “usual and customary” charges for the North Texas area. As an
important component of our professional relationship, following are WBSSC financial policies to ensure you have a clear understanding of our financial policies.
Methods of Payment: As a courtesy to you, WBSSC will bill your insurance provider with a copy of your current insurance card (which must be presented at each visit or kept current on file in our office). If you do not have insurance or current insurance information, payment is due at the time services are rendered. If payment for an unpaid balance(s) has not been paid (or arrangements made for a payment plan) within 90 days of service, your balance will be sent to a collection agency for debt recovery. For your convenience, WBSSC accepts cash, checks, Visa, MasterCard, Discover, and American Express along with all debit cards. Please note there is a $50 fee charge for all checks returned from the bank due to insufficient funds.
Insurance Participation: Dr. Jeff Eidsvig, D.C., PLLC participates with many PPO and POS insurance plans which allows WBSSC to accept assignment of benefits. If payment is not received from your insurance carrier with our contract limits, all balances will be the your responsibility. If WBSSC does not have a contract with your insurance carrier, you are responsible for payment in full at the time of service and considered a “self pay” patient.
Insurance Plans: As a component of the parameters of our contracts, WBSSC collect co-‐payments, co-‐insurance, deductibles, and past due balances at each visit. If payments are not received and your account has a balance, you will be asked to reschedule your appointment until payment arrangements are made.
Contracted Insurance Companies and Additional Fees: Dr. Jeff Eidsvig, D.C., PLLC is contracted “IN NETWORK” with most insurance carriers. Please ask our staff if your plan is included. NOTE: WBSSC offers procedures/services NOT covered by most insurance carriers; therefore, you will be responsible for full payment of these services/procedures when services are rendered.
Procedures NOT Typically Covered By Insurance Carriers (You may file yourself): Hyperbaric Oxygen Therapy Treatments, Massage Therapy, and Biocorrect Orthotics
I have read and understand the insurance and financial policies of Willow Bend Sports & Spine Center, the office of Dr. Jeff Eidsvig, D.C., PLLC
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Signature of Patient/Legal Guardian Date
Willow Bend Sports & Spine Center
Office Policies
First Name: ___________________________________________ Last Name: ______________________________________________
10 Minute Late Policy: Patients arriving to our office over ten (10) minutes past their schedule appointment time will be asked to reschedule to another time and/or date.
No Show Policy: Patients scheduled for appointments who fail to show up will be documented as a “No Show” and will be assessed and responsible for payment of “No Show Fee”: $100 for New Patients and $50 for Existing Patients.
Walk In Appointments: Willow Bend Sports & Spine Center is an appointment only office and walk in appointments are not available.
Payment: All payments are due at time of service. Due to the high cost of billing, patients unable to make payment at the time of service will be rescheduled and required to submit payment prior to another appointment another can be scheduled. Accepted methods of payment include cash, check, credit, and debit cards. Patients are responsible for their account balances, and expected to pay within 90 days or their balance will be sent to a collection agency. Per insurance company policies, benefits quoted to our staff via your insurance provider are “not guaranteed” until submitted and processed by your insurance provider.
Patient Termination Policy: A patient may be terminated from the office at the discretion of the patient’s doctor/staff. Common reasons include, but are not limited to: use of foul language, chronic non-‐compliance with recommended treatment, and abusive behavior to staff, doctors, visitors, or other patients.
Medical Form or Medical Request Form Completion: Please be aware our staff requires 5-‐7 business days to complete all medical forms or requests.
Copying of Medical Records: Patients requesting copies of their medical records will be assessed a $25.00 fee for the first 25 pages with an additional fee of $0.75/page. No fee will be assessed, when an abstract or referral is sent to a continuing care provider. A “Medical Records Release” of
information must be signed and submitted to our office by the patient/or guardian of patient prior processing all requests.
I have read and understand the office policies of Willow Bend Sports & Spine Center, the office of Dr. Jeff Eidsvig, D.C., PLLC
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Signature of Patient/Legal Guardian Date
