Patient Insurance Information

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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  the  

treatment  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:_______________________________

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Patient  History  

 

Patient  Medications:    (Please  include  Vitamins,  Herbs,  or  Supplements)  

_____________________________

___________________________

_____________________________

___________________________

_____________________________

___________________________

Past  Medical  Conditions/Hospitalizations/Surgeries  

_____________________________

___________________________

_____________________________

___________________________

Patient  Allergies:    (Please  list  ALL  food  and  medicine  allergies)  

_____________________________

___________________________

_____________________________

___________________________

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.    

 

____________________________________________________________________    

               ____________________________  

Signature  of  Patient/Legal  Guardian             Date  

 

Insurance  Authorization:    

I  hereby  authorize  the  release  of  medical  or  other  information  to  my  

insurance  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  health  

information.    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  

 

____________________________________________________________________    

               ____________________________  

Signature  of  Patient/Legal  Guardian             Date  

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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  

   

____________________________________________________________________    

               ____________________________  

Signature  of  Patient/Legal  Guardian             Date  

 

     

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