Reminders will be given 48 hours in advance for all appointments.

APPOINTMENT REMINDER FORM FOR CHIROPRACTIC PATIENTS

Date: ____________________________________________________________ Name: ____________________________________________________________ Please check the box with the preferred way you choose to be notified of your appointment time (Please only select one option).

Phone call reminders are no longer available for Chiropractic appointments.

□

□

Cell Phone Carrier (Verizon, AT&T, Sprint, Etc…) _____________________ OR

□

Reminders will be given 48 hours in advance for all appointments. MISSED APPOINTMENTS:

A 24 hour cancellation policy is in effect for all chiropractic services. We reserve the right to charge for missed appointments. If 24 hour notice is not given, you will be billed $30 for the session. If less than 24 hour notice is given, every effort by our staff will be made to fill the appointment from the Waiting List. If it cannot be filled, you will be charged.

For VA patients – If you miss more then 3 appointments without a 24 hour cancellation, our only recourse is to discontinue care.

COMPLETE CHIROPRACTIC & BODYWORK THERAPIES FINANCIAL POLICY/AUTHORIZATION AND ASSIGNMENT Thank you for choosing Complete Chiropractic & Bodywork Therapies as one of your health care providers. Please understand that payment of your bill is considered a part of your commitment here. The following is a statement of our Financial Policy, which we request you read, and sign prior to any treatment.

All New Patient paperwork must be filled out and completed prior to seeing your practitioner.

 Full payment is due at the time of services rendered, unless special arrangements have been made in advance.

 I assign payment to be made directly to Complete

Chiropractic & Bodywork Therapies for services billed to my insurance that are outstanding.

 We accept cash, checks or Visa/MasterCard.

 For massage therapy services not covered by your insurance, we accept cash or check only. Payment is made directly to the practitioner.

INSURANCE:

 We are participating providers of BCBS Traditional and BCBS PPO.

 Any other insurance is “Out of Network” in our office. Some insurances doprovide coverage for chiropractic services. Our Financial Coordinator Kendra, can call and check to see if your

insurance may provide benefits for services received at our office.

 We ask that all co pays and deductibles be paid at time of service.

 I authorize the release of any information necessary to my insurance provider, attorney or adjuster, as needed to process my claims.

 Be aware that some, perhaps all, of the services provided may be non-covered services and not considered reasonable and necessary under the Medicare Program and/or other medical insurance. USUAL AND CUSTOMARY RATES:

Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are

responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates.

 Adult patients are responsible for full payment at time of service.

 When an adult accompanies a minor they are responsible for the payment.

 An unaccompanied minor may make payment by credit card, cash or check at time of service.

MISSED APPOINTMENTS:

A 24 hour cancellation policy is in effect for all chiropractic services. We reserve the right to charge for missed appointments. If 24 hour notice is not given, you will be billed $30.00 for the session. If you have any questions about our Financial Policy you may direct them to Kendra, the Financial Coordinator.

I have read the Financial Policy. I understand and agree to this Financial Policy. I authorize Linda Berry, DC or Kathleen Dvorak, DC to provide care for the examination and treatment of my case. I am ultimately responsible for all charges incurred, including any collection efforts or court fees. I hereby consent to any statements stated above, that apply to my situation. Copies of these statements are as legal and binding as the original.

Signature/Date: ________________________________________________ Consent to Treat a Minor

I hereby authorize the doctor to treat my son or daughter.

Name of child: __________________________________________________ Name of Parent/Guardian: _____________________________Date: _______

Complete Chiropractic & Bodywork Therapies 2020 Hogback Rd. Suite 7

Ann Arbor, MI 48105

Electronic Health Records Intake Form

First Name:_________________________ Last Name:_________________________

Email address: _________________@_________________

Preferred method of communication for patient reminders (Circle one): Email / Phone / Mail

DOB: __/__/____ Gender (Circle one): Male / Female Preferred Language: __________________ 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 (Caucasian) Native Hawaiian or Pacific Islander / Other / I Decline to Answer

Ethnicity (Circle one): Hispanic or Latino / Not Hispanic or Latino / I Decline to Answer

Are you currently taking any medications? If necessary, use back of form for additional entries or provide a separate sheet of your medications. (Please include regularly used over the counter medications)

Medication Name Dosage and Frequency (i.e. 5mg once a day, etc.)

Do you have any medication allergies?

Medication Name Reaction Onset Date Additional Comments

□

Patient Signature: _____________________________________________ Date:________________ For office use only

Complete Chiropractic & Bodywork Therapies

2020 Hogback Rd. Suite 7

Ann Arbor, MI 48105

(734) 677-1900

NOTICE OF PRIVACY PRACTICES Per HIPAA REGULATIONS

Consent for Purposes of Treatment, Payment and Healthcare Operations

THIS NOTICE DESCRIBES HOW MEDICAL/PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I acknowledge that Complete Chiropractic & Bodywork Therapies “Notice of Privacy Practices” has been provided to me.

I understand I have the right to review Complete Chiropractic & Bodywork Therapies Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of bills or in the performances of healthcare operations at Complete Chiropractic & Bodywork Therapies. The Notice of Privacy Practices is also provided on request at the main administration desk. This notice of Privacy Practices also describes my rights and Complete Chiropractic & Bodywork Therapies duties with respect to my protected health information.

Complete Chiropractic & Bodywork Therapies reserves the right to change the Privacy Practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of Privacy Practices by calling the office and requesting a revised copy to be sent via mail or may request a copy at the time of my next scheduled appointment.

_____________________________ ______________

Signature of Patient or Patient Representative Date ___________________________________________

Name of Patient or Patient Representative

___________________________________________ Description of Patient Representative’s Authority

___________________________________________ _____________________

COMPLETE CHIROPRACTIC & BODYWORK THERAPIES PATIENT/CLIENT UPDATE FORM

Date ______________________ Referral Source________________________________ Name______________________________________________________________________________

Last First Middle Name I prefer to be called

Address ____________________________________________________________________________

City State Zip

Phone (___)___________________(___)____________________(___)__________________________

Home Work Cell/Pager

Email ____________________________Social Security# __________________Male ____Female ____

Occupation _________________________Employer _________________________________________

Date of Birth ____________________________Age _________Marital Status: S M W D Partner

Emergency Contact _____________________________________________________________________

Name Phone # Relationship

COMPLETE CHIROPRACTIC & BODYWORK THERAPIES PATIENT/CLIENT COMPLAINT/SYMPTOM FORM

Date: ________________Name: ___________________________________________________ Height______Weight__________

Numbness = = = Dull Ache OOO Burning XXX Sharp/Shooting / / / Pins/Needles + + + Other ^ ^ ^

Please state your chief complaint:

______________________________________________________________________________ ______________________________________________________________________________ How long have you had the symptoms?

______________________________________________________________________________ How did the condition begin?

______________________________________________________________________________ How long did the symptoms last?

______________________________________________________________________________ What makes it worse?

______________________________________________________________________________ What makes it better?

______________________________________________________________________________ How would you describe your pain on a scale of 1 to 10? Circle or write down for each complaint: (0 is none – 10 is severe) 0 1 2 3 4 5 6 7 8 9 10

_____________________________________________________________________________________ _____________________________________________________________________________________

Name:_______________________________Date:_________ Page 2 Previous treatment for this complaint (include any doctors names, dates treated, test results, or home remedies:__________________________________________________________ _________________________________________________________________________

(If you need more room; please write on back of sheet)

X-rays, MRI’s or CT’s Where Taken Date

Past Surgical History

Surgery Year

Hospitalizations (other than surgery)

Reason Year

Accidents/Injuries

Accident/Injury Year

Current medications/supplements _______________________________________________ __________________________________________________________________________ Known allergies to medications/supplements______________________________________ __________________________________________________________________________ Exercise, type and frequency:__________________________________________________ __________________________________________________________________________ Describe your typical diet for

Breakfast:____________________________________________________________ Lunch: ____________________________________________________________ Dinner: ____________________________________________________________ How much of the following do you consume daily?

Water:__________ Milk:__________ Soda:__________ Coffee________ Cigarettes:_______ Sweets:________ Alcohol:________ Tea__________ Abdominal gas frequently?____#of bowel movements daily?_________________________ List any recent travel:_________________________________________________________ Age of mattress:______Regular:_____Waterbed_____Fouton:____Sleep Position_________ Do you like your job?____How do you relieve stress?_______________________________ Spiritual/Religious affiliation/Meditation/Prayer____________________________________ List hobbies:________________________________________________________________ With whom do you live?_______________________________________________________ Estimate the stress in your life: _____None _____Mild _____Moderate _____Great Date of last physical exam?____________________________________________________ Have you ever had a professional massage, Polarity Therapy or craniosacral

therapy?_______________

Page 3

Name______________________Date_____________

Please CHECK conditions that apply and CIRCLE to specify further as necessary: Past Current SPECIFY

Abdominal Allergies Anxiety

Arthritis, osteo or rheumatoid Asthma

Bleeding Disorder Blood Clots

Blood Pressure high or low Cancer Chest Pain Chicken Pox/Measles/Mononucleosis Cough Dental/TMJ Depression Diabetes Digestive Disorder Dizziness/Fainting spells Ear Disorders/Hearing loss Eye Disorders Fibromyalgia/Chronic Fatigue Genetic Disease Gout Headaches/Migraines Heart Disorder Hepatitis Hernia Kidney Disorder Leg cramps Low blood sugar Lung Disorder Lupus Malaria Nausea/vomiting Nose problems/Smell

Polio, Rheumatic Fever, Scarlet Fever Seizures

Sinus Problems Skin Disease Spinal problems Stroke

Sudden weight loss/gain Thyroid Disease Ulcers

Varicose Veins Venereal Disease

Page 4 Name________________________Date__________________

Women Only Men Only

Past Current Problems with Breasts Past Current Prostate Problems

Vaginal Itch/Discharge Impotence

Painful Intercourse Swollen or Painful Testicle

Take Birth Control Pills Discharge

Irregular Cycles/Bleeding

Hot Flashes

Difficulty Conceiving

Age of First Period

# of Pregnancies

# of Miscarriages

# of Abortions

Passed Menopause at Age Date/Onset of last period: # of Days between cycles:

Family History: State Health Problems or

Relationship Age, if Living Age, at Death Cause of Death

Father _________ _________ ___________________________________ Mother _________ _________ ___________________________________ Brothers _________ _________ ___________________________________ Sisters _________ _________ ___________________________________ Grandfather _________ _________ ___________________________________ Grandfather _________ _________ ___________________________________ Grandmother _________ _________ ___________________________________ Grandmother _________ _________ ___________________________________