Electronic Health Records Intake Form In compliance with requirements for the government EHR incentive program

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Legal Name: __________________________ Preferred Name:___________________ How did you hear about our office? _____________________________________ If referred, whom may we thank for referring you to this office?_______________ Home Phone: ________________________ Cell Phone: ________________________ Email address: ___________________________________________________________ Address: ________________________________________________________________

City: _________________________________ State: __________ Zip: _______________ Preferred method of communication for patient reminders (Circle one): Email / Phone / Mail DOB: ____ /____/____ Gender (Circle one): Male / Female Name and Number of Emergency Contact:

_________________________________________________________________________ Preferred Language: __________________ Marital Status: Married/ Widowed/Single Smoking Status (Circle one): Every Day Smoker / Occasional Smoker

Former Smoker / Never Smoked CMS requires providers to report both race and ethnicity

Race (Circle one): American Indian or Alaska Native / Asian / Black or African American / White/ Native Hawaiian or Pacific Islander / Other / Decline to Answer

Ethnicity (Circle one): Hispanic or Latino / Non Hispanic or Latino / I Decline to Answer Are you currently taking any medications? [ ] I’ve attached a list of my medications

Medication Name Dosage

Do you have any medication allergies? [ ] I’ve attached a list of my allergies

Medication Name Reaction

[ ] I would like to receive a copy of my clinical summary after every visit. (These summaries are often blank as a result of the nature and frequency of chiropractic care)

Colony Chiropractic Dr. Robert Arsenault.

Application for Care at Colony Chiropractic

Electronic Health Records Intake Form

In compliance with requirements for the government EHR incentive program

Co nsult at io n No te s

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COLONY CHIROPRACTIC HEALTH HISTORY FORM

Name: ____________________________________________________ Date: _________________ Please draw on the diagram where you are experiencing symptoms:

In order for us to serve you best, please circle the most appropriate answers and be as detailed as possible. If you have multiple symptoms please describe each one below.

Where is the location of your problem? __________________________________________________________ List any other problem areas _______________________________________________________________

Onset: When did the symptom most recently occur? _______________________________________________

What caused the problem? Prolonged position, over exertion, accident/injury, other: ______________________ What makes this better? (ice, heat, rest, meds, nothing, etc.) _________________________________________ What makes this worse? (movement, bending, standing, etc) _________________________________________ Describe the quality of the pain: Sharp Achy Dull Shooting Stiff Tight Burning Throbbing Numb Tingling Rate the severity of the pain (0 no pain & 10 worst pain) 1 – 2 – 3 – 4 – 5 – 6- 7 – 8 –9 – 10

Frequency of the pain: Constant (100%) Frequent (75-50%) Occasional (50-25%) Intermittent (25% or less)

Does the pain radiate? Yes or No; If yes to what part of the body? ____________________________________ Have you ever had this problem before? Yes or No If yes when? _____________________________________ What have you used in the past for this? (medications, chiropractic, massage) other: ______________________ How does your current condition interfere with your activities? ______________________________________ Have you been to a chiropractor before? Yes or No. If yes when and where: ____________________________ Review of Systems: Please list any of these problems you have now or had in the past.

Musculoskeletal:

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Name: _______________________________________________________ Date: _______________________ Neurological:

[ ] Anxiety [ ] Depression [ ] Memory issues [ ] Headaches [ ] Dizziness [ ] Numbness

Sensory:

[ ] Chronic ear infection [ ] Ringing in ears [ ] Hearing loss

[ ] Hoarseness [ ] Blurred vision [ ] Difficulty swallowing Cardiovascular:

[ ] Chest pain [ ] Palpitations [ ] Difficulty breathing [ ] High blood pressure [ ] High cholesterol [ ] Lower extremity edema Respiratory:

[ ] Asthma [ ] Apnea [ ] Emphysema

[ ] Hay fever [ ] Shortness of breath [ ] Pneumonia Gastrointestinal (Digestive):

[ ] Blood in stool [ ] Ulcer [ ] Nausea [ ] Heartburn [ ] Constipation [ ] Diarrhea Genitourinary:

[ ] Kidney stones [ ] Incontinence [ ] Painful urination [ ] Prostate issues [ ] Frequent urination [ ] Blood in urine Endocrine:

[ ] Thyroid issues [ ] Immune disorders [ ] Hypoglycemia [ ] Frequent infections [ ] Diabetes [ ] Low energy

Skin:

[ ] Skin cancer [ ] Psoriasis [ ] Eczema [ ] Acne [ ] Excessive hair loss [ ] New rashes

Constitutional:

[ ] Fainting [ ] Low libido [ ] Poor appetite [ ] Fatigue [ ] Weakness [ ] Sudden weight gain/loss Past Personal, Family & Social History:

Illnesses: Please check any of the illnesses you have now or had in the past.

[ ] AIDS [ ] Alcoholism [ ] Allergies

[ ] Arteriosclerosis [ ] Cancer [ ] Chicken pox [ ] Diabetes [ ] Epilepsy [ ] Glaucoma

[ ] Goiter [ ] Gout [ ] Heart disease

[ ] Heapatis [ ] HIV positive [ ] Malaria [ ] Measles [ ] Multiple sclerosis [ ] Mumps [ ] Polio [ ] Rheumatic fever [ ] Scarlet fever [ ] Sexually transmitted disease [ ] Stroke [ ] Tuberculosis

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Name: _______________________________________________________ Date: _______________________ Surgeries:

[ ] Appendix removal [ ] Bypass surgery [ ] Cancer [ ] Cosmetic surgery [ ] Eye surgery [ ] Hysterectomy [ ] Pacemaker [ ] Tonsils removed [ ] Vasectomy [ ] Heart surgery – list below [ ] Spine – list below [ ] Other – list below

________________________ ________________________ _________________________ ________________________ ________________________ _________________________ Accidents:

[ ] Had a fracture or broken bone [ ] Had a spine or nerve disorder [ ] Been knocked unconscious [ ] Involved in an auto accident [ ] Had a sports injury/trauma [ ] Slip and fall

Medications: [ ] Prescription medications [ ] Over the counter medications

Family History: Please list any diseases that may run in your family such as heart disease, diabetes and cancer. Mother: _________________________________________________________________________________ Father: __________________________________________________________________________________ Sisters: __________________________________________________________________________________ Brothers: ________________________________________________________________________________ Social History:

Alcohol use [ ] None [ ] Daily [ ] Weekly. How much? ___________________________________________ Tobacco use [ ] None [ ] Daily [ ] Weekly. How much? ___________________________________________

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Informed Consent to Chiropractic Treatment

The nature of chiropractic treatment: The doctor will use his/her hands or a mechanical device in order to move your joints. You may feel a "click" or "pop", such as the noise when a knuckle is "cracked", and you may feel movement of the joint.

Possible Risks: As with any health care procedure, complications are possible following a chiropractic

manipulation. Complications could include fractures of bone, muscular strain, ligamentous sprain, dislocations of joints, or injury to intervertebral discs, nerves or spinal cord. Cerebrovascular injury or stroke could occur upon severe injury to arteries of the neck. A minority of patients may notice stiffness or soreness after the first few days of treatment.

Probability of risks occurring: The risks of complications due to chiropractic treatment have been described as "rare", about as often as complications are seen from the taking of a single aspirin tablet. The risk of

cerebrovascular injury or stroke, has been estimated at one in one million to one in twenty million, and can be even further reduced by screening procedures. The probability of adverse reaction due to ancillary procedures is also considered "rare".

Other treatment options which could be considered may include the following:

Over-the-counter analgesics. The risks of these medications include irritation to stomach, liver and

kidneys, and other side effects in a significant number of cases.

Medical care, typically anti-inflammatory drugs, tranquilizers, and analgesics. Risks of these drugs

include a multitude of undesirable side effects and patient dependence in a significant number of cases.

Hospitalization in conjunction with medical care adds risk of exposure to virulent communicable disease

in a significant number of cases.

Surgery in conjunction with medical care adds the risks of adverse reaction to anesthesia, as well as an

extended convalescent period in a significant number of cases.

Risks of remaining untreated: Delay of treatment allows formation of adhesions, scar tissue and other

degenerative changes. These changes can further reduce skeletal mobility, and induce chronic pain cycles. It is quite probable that delay of treatment will complicate the condition and make future rehabilitation more difficult.

Unusual risks: I have had the following unusual risks of my case explained to me.

I have read the explanation above of chiropractic treatment. I have had the opportunity to have any questions answered to my satisfaction. I have fully evaluated the risks and benefits of undergoing treatment. I have freely decided to undergo and comply with the recommended treatment, and hereby give my full consent to treatment. PATIENT:

___________________________________ _________________________________ ________________

Printed Name Signature Date

WITNESS:

___________________________________ _________________________________ ________________

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Colony Chiropractic

ASSIGNMENT AND PAYMENT AGREEMENT

THIS AGREEMENT, entered into this date by and between ________________________________, herein after called “Patient” and Colony Chiropractic, herein after called “Provider”.

WHEREAS Patient desires to receive health care services from Provider and desires to assign certain rights and benefits to Provider as an inducement to cause Provider to wait for payment of such benefits, it is hereby agreed:

1. Patient assigns to Provider any and all benefits payable by Patient’s insurance or health care plan(s) as a result of charges incurred by Patient for health care services and supplies furnished by Provider. Patient also assigns to Provider any and all contractual rights Patient has against any insurance company, health care benefit plan, or any other party contractually liable to Patient for payment of health care costs incurred by Patient as a result of services rendered by Provider. This assignment of benefits and contractual rights relating to those benefits includes, but is not limited to the following described policies or plans:

_______________________________________________________________________________________________________. This assignment of benefits and contractual rights to those benefits shall not exceed the total amount of charges incurred by Patient for services rendered by Provider. The total amount paid to Provider from all sources shall not exceed the total amount of Provider’s billings for services. Patient agrees that payment for services rendered by Provider is due upon receipt of said services and Provider’s acceptance of Patient’s assignment of benefits is a convenience to Patient, and that Provider may revoke this assignment if Patient breaches this Agreement.

2. Patient hereby directs all insurers and other persons responsible for Patient’s health care costs to make all payments for health care services rendered by Provider directly to Provider.

3. Patient agrees to waive any applicable statute of limitations which may at any time interfere with Provider’s right to collect for services rendered to Patient.

4. Patient agrees that in the event Patient receives any check, draft, or other payment subject to this Agreement, Patient will act as fiduciary agent for Provider and will immediately deliver said check, draft or payment to Provider. Provider agrees to apply the proceeds from the check, draft or payments to Patient’s debt for services rendered.

5. A photocopy or facsimile of this document shall be as binding as the document bearing original signatures. At the time each claim is submitted, a copy of the claim will be stored for safekeeping in Patient’s file and may be picked up by the Patient/insured at any time or will, upon request by Patient/insured, be mailed to a designated address.

6. Patient agrees to be responsible for any deductibles or co-payments required by the terms of any applicable insurance or health care plan. Patient further agrees to pay for any services not covered by Patient’s insurance or health care plan. In the event Patient’s insurance carrier or health care plan requests reimbursement of any amounts paid to Provider, Patient shall be solely responsible for any such reimbursement and agrees to hold harmless and indemnify the Provider from any such claim for reimbursement.

7. In the event that any Section or provision of this Agreement is legally void, invalid, or unenforceable, all other Sections and provisions of this Agreement shall remain in full force and effect.

8. The assignments and agreements contained in this document may not be revoked by Patient without the express written consent of the Provider.

9. In the event of any default in the performance of this Assignment, all amounts due Provider shall become immediately due and payable and Patient agrees to pay all costs of collection and attorney’s fees incurred by Provider in any arbitration or litigation which shall arise therefrom. From and after the date of any such breach, the amount due Provider shall bear interest at the rate of 10% per annum.

IN WITNESS WHEREOF, this Agreement has been entered into the date and year set forth below.

___________________________________ _________________________________ ________________

Patient Printed Name Signature Date

___________________________________ _________________________________ ________________

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Colony Chiropractic

NOTICE OF PRIVACY PRACTICE

This office is required to notify you in writing, that by law, we must maintain the privacy and confidentiality of your Personal Health Information. In addition we must provide you with written notice concerning your rights to gain access to your health information, and the potential circumstances under which, by law, or as dictated by our office policy, we are permitted to disclose information about you to a third party without your authorization. Below is a brief summary of these circumstances. If you would like a more detailed explanation, one will be provided to you. Once you have read this notice, please sign the last page, and return only the signature page (page 2) to our front desk receptionist. Keep this page for your records.

PERMITTED DISCLOSURES:

1. Treatment purposes- discussion with other health care providers involved in your care.

2. Inadvertent disclosures- open treating areas mean open discussion. If you need to speak privately to the doctor, please let our staff know so we can place you in a private consultation room.

3. For payment purposes - to obtain payment from your insurance company or any other collateral source. 4. For workers compensation purposes- to process a claim or aid in investigation

5. Emergency- in the event of a medical emergency we may notify a family member

6. For Public health and safety - in order to prevent or lessen a serious or eminent threat to the health or safety of a person or general public.

7. To Government agencies or Law enforcement – to identify or locate a suspect, fugitive, material witness or missing person.

8. For military, national security, prisoner and government benefits purposes.

9. Deceased persons –discussion with coroners and medical examiners in the event of a patient’s death. 10. Telephone calls or emails and appointment reminders -we may call your home and leave messages

regarding a missed appointment or apprize you of changes in practice hours or upcoming events. 11. Change of ownership- in the event this practice is sold, the new owners would have access to your PHI. YOUR RIGHTS:

1. To receive an accounting of disclosures

2. To receive a paper copy of the comprehensive “Detail” Privacy Notice 3. To request mailings to an address different than residence

4. To request Restrictions on certain uses and disclosures and with whom we release information to, although we are not required to comply. If, however, we agree, the restriction will be in place until written notice of your intent to remove the restriction.

5. To inspect your records and receive one copy of your records at no charge, with advanced notice

6. To request amendments to information. However, like restrictions, we are not required to agree to them. 7. To obtain one copy of your records at no charge, when timely notice is provided (72 hours). X-rays are

original records and you are therefore not entitled to them. If you would like us to outsource them to an imaging center, to have copies made, we will be happy to accommodate you. However, you will be responsible for this cost.

COMPLAINTS:

If you wish to make a formal complaint about how we handle your health information, please call our Privacy

Officer at (352) 430-3355. If she/he is unavailable, you may make an appointment with our receptionist to see

her/him within 72 hours or 3 working days. If you are still not satisfied with the manner in which this office

handles your complaint, you can submit a formal complaint to:

DHHS, Office of Civil Rights 200 Independence Ave. SW Room 509F HHH Building

Washington DC 20201

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Patient initials: _________-retaining page 1 of 2

Colony Chiropractic’s NOTICE REGARDING YOUR RIGHT TO PRIVACY continued….

I have received a copy of Colony Chiropractic’s Patient Privacy Notice. I understand my rights as well as the practices duty to protect my health information, and have conveyed my understanding of these rights and duties to the doctor. I further understand that this office reserves the right to amend this ‘Notice of Privacy Practice” at a time in the future and will make the new provisions effective for all information that it maintains past and present.

I am aware that a more comprehensive version of this “Notice” is available to me upon request. At this time, I do not have any questions regarding my rights or any of the information I have received.

_______________________________________________ ______________

Patient’s Name DOB

_______________________________________________ ______________

Patient signature Date

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369 Colony Blvd. The Villages, FL, 32162 Phone: 352-430-3355 Fax: 800-884-5238

OFFICE FINANCIAL POLICY

We would like to thank you for choosing Colony Chiropractic. In order to maintain a good doctor-patient relationship, we would like to keep you informed of our current financial policy. If you have any questions, please ask our staff for clarification. We would like for you to completely read and understand this policy.

1. Payment. Payment is expected at the time of service. We accept cash, checks, and all major credit cards. Payment includes all insurance co-pays, co-insurance, unmet deductibles, and any non-covered charges from your insurance company. If you do not have insurance coverage, you will be responsible for payment in full at the time of your visit. ALL SALES ARE FINAL on any products purchased in our office. Any outstanding balance on your account, after adjusting for all of your insurance’s responsibilities, will be billed to you. Any credit balances on your account will be held by this office and applied to future visits unless a request for refund is made in writing. Please allow 30 days for any request for refund to be processed. Patients with an outstanding balance more than 90 days overdue must make arrangements for payment prior to scheduling appointments. There will be a $35 service charge for any returned checks.

2. Insurance. We require a copy of your insurance card and driver’s license to be on file with us. It is the patient’s responsibility to provide us with current insurance information. We will file with your insurance company, even if we are out of network. Not all insurance

companies cover all services. Medical services that are considered by your insurance company as non-covered, out of network, or not medically necessary will be your

responsibility. While we verify coverage and benefits on your policy, it is the Explanation of Benefits (EOB) that determines coverage. If the EOB pays something different than was explained previously, you would be responsible for the difference.

3. Appointments. We value the time we have set aside to see and treat you. If you are unable to keep an appointment, we would appreciate 24-hour notice. If you are 15 minutes late to your appointment, we will try to work you into our schedule. If you are 30 minutes late to your appointment, we will have to reschedule your appointment. If you do not show up for your appointment, we will notify you of the missed appointment. If you do not show up for three consecutive appointments, you may be discharged from the practice. Patients with a delinquent balance must pay for any past due amounts before new appointments can be scheduled unless the patient has made prior payment arrangements with our office. 4. Request for Records. If a patient requests records from our office, they must do so in

writing and will be responsible for a fee of $1.00 per page for the first 25 pages and $0.25 per page thereafter. If the records are emailed or faxed, there is a minimum charge of $20. 5. Billing Office. If you have any questions in regards to any of your billing statements, please

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Patient initials: _________-retaining page 1 of 2

Colony Chiropractic’s NOTICE REGARDING OUR FINANCIAL POLICY continued….

I have received a copy of Colony Chiropractic’s Financial Policy. I understand my rights and responsibilities. I further understand that this office reserves the right to amend this Policy at any time in the future and will make the new provisions effective for all information that it maintains past and present. At this time, I do not have any questions regarding my rights or any of the information I have received.

_______________________________________________ ______________

Patient’s Name DOB

_______________________________________________ ______________

Patient signature Date

_______________________________________________ ______________

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