Patient Name: Patient Signature:

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Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to that information. Please review this notice carefully. The full HIPPA notice is available at the front

desk for your review if you would like.

This Practice is committed to maintaining the privacy of your protected health information (“PHI”), which includes information about your health condition and the care and treatment you receive from the Practice. The creation of a record detailing the care and services you receive helps this office to provide you with quality health care. This Notice details how your PHI may be used and disclosed to third parties. This Notice also details your rights regarding your PHI. The privacy of PHI in patient files will be protected when the files are taken to and from the Practice by placing the files in a box or brief case and kept within the custody of a doctor or employee of the Practice authorized to remove the files from the Practice’s office. It may be necessary to take patient files to a facility where a patient is confined or to a patient’s home where the patient is to be examined or treated. If you have further questions, please contact the compliance officer, Andrew Sanders D.C.

No Consent Required

1. The Practice may use and/or disclose your PHI for the purposes of:

a) Treatment – In order to provide you with the health care you require, the Practice will provide your PHI to those health care professionals, whether on the Practice’s staff or not, directly involved in your care so that they may understand your health condition and needs. For example, a physician treating you for a condition or disease may need to know the results of your latest physician examination by this office.

b) (b) Payment – In order to get paid for services provided to you, the Practice will provide your PHI, directly or through a billing service, to appropriate third party payers, pursuant to their billing and payment requirements. For example, the Practice may need to provide the Medicare program with information about health care services that you received from the Practice so that the Practice can be properly reimbursed. The Practice may also need to tell your insurance plan about treatment you are going to receive so that it can determine whether or not it will cover the treatment expense.

c) (c) Health Care Operations – In order for the Practice to operate in accordance with applicable law and insurance requirements and in order for the Practice to continue to provide quality and efficient care, it may be necessary for the Practice to compile, use and/or disclose your PHI. For example, the Practice may use your PHI in order to evaluate the performance of the Practice’s personnel in providing care to you.

2. The Practice may use and/or disclose your PHI, without a written Consent from you, in the following additional instances:

a. (a) De-identified Information – Information that does not identify you and, even without your name, cannot be used to identify you.

b. (b) Business Associate – To a business associate if the practice obtains satisfactory written assurance, in accordance with applicable law, that the business associate will appropriately safeguard your PHI. A business associate is an entity that assists the Practice in undertaking some essential function, such as an associate doctor, billing company or massage therapist that assists the office in submitting claims for payment to insurance companies or other payers.

c. (c) Personal Representative -To a person who, under applicable law, has the authority to represent you in making decisions related to your health care

d. (d) Emergency Situations:

3518 Riverside Dr. Suite 104, Upper Arlington, OH 43221 Phone: 614-569-4324


i. (i) for the purpose of obtaining or rendering emergency treatment to you provided that the Practice attempts to obtain your Consent as soon as possible; or

ii. (ii) to a public or private entity authorized by law or by its charter to assist in disaster relief efforts, for the purpose of coordinating your care with such entities in an emergency situation.

iii. (e) Communication Barriers – If, due to substantial communication barriers or inability to communicate, the Practice has been unable to obtain your Consent and the Practice determines, in the exercise of its professional judgment, that your Consent to receive treatment is clearly inferred from the circumstances.

e. Public Health Activities – Such activities include, for example, information collected by a public health authority, as authorized by law, to prevent or control disease and that does not identify you and, even without your name, cannot be used to identify you.

f. Abuse, Neglect or Domestic Violence – To a government authority if the Practice is required by law to make such disclosure; if the Practice is authorized by law to make such a disclosure, it will do so if it believes that the disclosure is necessary to prevent serious harm

g. Health Oversight Activities – Such activities, which must be required by law, involve government agencies and may include, for example, criminal investigations, disciplinary actions, or general oversight activities relating to the community’s health care system.

h. Judicial and Administrative Proceeding – For example, the Practice may be required to disclose your PHI in response to a court order or a lawfully issued subpoena.

i. Law Enforcement Purposes – In certain instances, your PHI may have to be disclosed to a law enforcement official. For example, your PHI may be the subject of a grand jury subpoena. Or, the Practice may disclose your PHI if the Practice believes that your death was the result of criminal conduct.

j. Coroner or Medical Examiner – The Practice may disclose your PHI to a coroner or medical examiner for the purpose of identifying you or determining your cause of death.

k. Organ, Eye or Tissue Donation – If you are an organ donor, the Practice may disclose your PHI to the entity to whom you have agreed to donate your organs.

l. Research – If the Practice is involved in research activities, your PHI may be used, but such use is subject to numerous governmental requirements intended to protect the privacy of your PHI and that does not identify you and, even without your name, cannot be used to identify you.

m. Avert a Threat to Health or Safety – The Practice may disclose your PHI if it believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and the disclosure is to an individual who is reasonably able to prevent or lessen the threat.

n. Workers’ Compensation – If you are involved in a Workers’ Compensation claim, the Practice may be required to disclose your PHI to an individual or entity that is part of the Workers’

Compensation system.

Patient Name:_______________________________

Patient Signature:____________________________ Date:______________________

3518 Riverside Dr. Suite 104, Upper Arlington, OH 43221 Phone: 614-569-4324


New Patient Forms

3518 Riverside Dr. Suite 104, Upper Arlington, OH 43221 Phone: 614-569-4324 Fax: 614-360-3420 Email: Website:

Do you allow Riverview Chiropractic to send you appointment reminders via email and or text message?

Yes No If yes mark Email Text

Do you allow Riverview Chiropractic to send periodic information regarding Riverview Chiropractic promotions and newsletters?

Yes No If yes mark Email Text


Marital Status:

Decline to Specify

Can we contact your PCP to give them updates of your treatment progress?

Yes No

How did you hear about us?

Spouse Name:__________________ Contact Info:____________________

Insurance Co. Name: Group #/Policy #/Member ID: Insurance Co. Contact Info (Phone/Email):

Age: Email Address: Birth Date:


Primary Care Phone/Email:

Referral Phone # or Address to Thank Them:

Relationship to Referral: Employer Phone:

Emergency Contact: Relationship: Emergency Contact Phone/Email:

Primary Care Physcian Name:

Patient Signature/Guardian's Signature Authorizing Care: Date:

Primary Care Address: Native Language: Ethnicity: Occupation: Employer: Cell Phone: City: Name: Date: ZIP: State: Address: Cell Carrier: Social #: Home Phone:

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and me. Therefore, I understand that Dr. Sanders will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to Riverview Chiropractic 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 and treatment and fees for professional services rendered me will immediately be due and payable.

Confidential Patient Info


Specifiy Other

Preferred Method of Payment

Preferred Method of Contact

Referral Name:

Single Decline to Specify

Cell Phone



New Patient Forms C Riverivew Chiropractic 2014 What kind of symptom(s) are you experiencing? (Please check and or fill in all that apply)

pain soreness stiffness tightness discomfort other

What side is your complaint(s)/pain on? (Please check all that apply)

right left both front back both front & back

How would you describe your symptom(s)? (Check/fill in appropriate box to all that apply)

deep dull achy burning numbing sharp shooting stiff tight pulling


Office Notes:


Office Notes:

What are your reason(s) for visiting our clinic?

When and what were you doing when the above symptom(s) started to happen?


What medications/drugs/supplements are you taking? How much and how often. (approximate) Have you had any major illnesses? If yes, describe and specify the outcome of each.

Pleast list or describe any major surgeries or operations you have had and when (approximate). Who have you seen for this condition(s) and did they help?

What have you done so far to help your symptom(s) and did you get relief?

New Patient Forms Chief Complaint & Patient History

What body section(s) are you experiencing the above symptom(s)? (Select appropriate chief complaint. Please keep it to three)

1st Chief Complaint 2nd Chief Complaint 3rd Chief Complaint


New Patient Forms

New Patient Forms C Riverivew Chiropractic 2014

Family History


Personal History

Alcohol Drinks per

Drug or Alcohol Dependence Coffee/Tea/Caffeinated Drinks

Cups/Cans per day Cancer

Rhematoid Arthritis Epilepsy

Chronic Back Problems Heart Problems Chronic Headaches Lung Problems High Blood Pressure Lupus


Indicate how much time you participate in each of the following activity(s) per day.

How do you sleep? (mark all that apply)

Do you sleep on your:

back belly side 1 pillow under head >1 pillow under head pillow between knees


What kind of mattress do you have and how old is it? (Select the right one and indicate from the drop down its age )

Which of the following are affected by your symptoms and what % of the time do they affect you?

working getting dressed

getting undressed reading studying eating urinating deficating Drug Allergies: Non-Drug Allergies: Office Notes:

Patient Health History

Pregnancy (# of Births) Birth Control Type: Tobacco walking running standing driving lifting >10 lbs training cycling sleeping sitting

studying playing sportsexercising

Memory foam w/box spring

Traditional Box Spring Automated/Manual Recliner

walking running standing driving lifting >10 lbs training cycling sleeping sitting

studying playing sportsexercising

Date: Patient Signature/Guardian's Signature Authorizing Care:

I certify that the above information is complete and accurate to the best of my

knowledge. I agree to notify the Doctor immediately whenever I have changes in my

health condition.

Water Bed

Tempur-pedic Sleep Number





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