PIP New Patient Form

Nob Hill Family Chiropractic 

Patient Demographics

History Of Complaint

On a scale of 0 to 10 with 10 being the worst pain and zero being no pain, rate your above complaints by typing in the number:

PLEASE MARK the areas on the body diagram with the following letters to describe your symptoms:

R = Radiating / B = Burning /  D = Duff / A = Aching 

N = Numbness / S = Sharp/Stabbing / T = Tingling

Past History 

If you have ever been diagnosed with any of the following conditions, please indicate with:

P for In the Past     C for Currently have     N for Never have had

PLEASE IDENTIFY ALL PAST and any CURRENT conditions you feel may be contributing to your present problem:

Family History

Social History

Hobbles - Recreational Activities - Exercise Regime: How does your present problem affect? (See Activities of Life form)

I hereby authorize payment to be made directly to Nob Hill Family Chiropractic for all benefits which may be payable under a healthcare plan or from any other collateral sources. I authorize utilization of this application, or copies thereof, for the purpose of processing claims and effecting payments, and further acknowledge that this assignment of benefits does not In any way relieve me of payment liability and that I will remain financially responsible to Nob Hill Family Chiropractic for any and all services I receive at this office.

NOB HILL FAMILY CHIROPRACTIC

Informed Consent

REGARDING: Chiropractic Adjustments, Modalities, and Therapeutic Procedures: 

I have been advised that chiropractic care, like all forms of health care, holds certain risks. While the risks are most often minimal, complications such as sprain/strain injuries, irritation of a disc condition, dislocations of joints, and although very rare, fractures, and possible stroke (estimated to be related In one in one million to one in two million cervical adjustments), have been associated with chiropractic adjustments.
Treatment objectives, as well as the risks associated with chiropractic adjustments and all other procedures provided at Nob Hill Family Chiropractic have been explained to me to my satisfaction and I have conveyed my understanding of both to the doctor. After careful consideration, I do hereby consent to treatment by any means, method, and or techniques, the doctor deems necessary to treat my condition at any time throughout the entire clinical course of my care.

REGARDING: X-Rays/Imaging Studies

FEMALES ONLY: Please read carefully, check the boxes, include the appropriate date, then sign below if you understand and have no further questions, otherwise see our front desk staff for further explanation.

By my signature below, I am acknowledging that the doctor and or a member of the staff has discussed with me the hazardous effects of ionization to an unborn child, and I have conveyed my understanding of the risks associated with exposure to X-rays. After careful consideration, I therefore do hereby consent to have the diagnostic x-ray examination the doctor has deemed necessary in my case.

21 Day                     Notice Notice of Initiation of Treatment

This document shall serve as formal notice to the insurer that the first examination or treatment of the claimant has occurred. While Florida Statute ;c( 627.736 requires medical providers to submit bills to insurance companies within 35 days of treatment, subsection (5)(c) allows medical providers to submit bills within 75 days of treatment if this notice is. provided within 21 days of the first examination or treatment Any deficiencies to this notice are deemed waived if they are not specifically objected to in writing before the 21 day window expires.

(c) With respect to any treatment or service; other than medical services billed by a hospital or other provider for emergency services and care as defined in s. 395.002 or inpatient services rendered at a hospital-owned facility, the statement of charges must be furnished to the insurer by the provider and may not include, and the insurer is not required to pay, charges for treatment- or services rendered more than 35 days before the postmark date or electronic transmission date of the statement, except for past due amounts previously billed on a timely basis under this paragraph, and except that, if the provider submits to the insurer a notice of initiation of treatment within 21 days after its first examination or treatment of the claimant, the statement may include charges for treatment or services rendered up to, but not more than, 75 days before the postmark date of the statement. The injured party is not liable for, and the provider may not bill the injured party for, charges that are unpaid because of the provider's failure to comply with this paragraph. Any agreement requiring the injured person or insured to pay for such charges is unenforceable.

This office is required, by law, to maintain the privacy and security of your Protected Health Information. We must provide you with written notice concerning your rights to your health Information, and the potential circumstances under which, by law, or as dictated by our office policy, we are permitted to use and 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. Please review carefully, sign receipt of acknowledgement, and return to our front desk staff. Keep this page for your records.

YOUR RIGHTS:
1. To inspect or obtain a copy of your records within 15 days of your request. We may charge a reasonable, cost-based fee for a copy. X-rays are original records, and you are therefore not entitled to them. If you would like us to outsource them to have copies made, we will be happy to accommodate you. However, you will be responsible for this cost.
2. To ask for amendments to your health information you think is incomplete or incorrect. We may say "no" to your request, but we'll tell you why in writing within 60 days.
3. To request confidential communications (contact you in a specific way or send mail to a different address).
4. To request restrictions on certain uses and disclosures, and with whom we release information to, although we are not required to comply. If we do agree, the restriction is in place until receiving written notice of your Intent to remove the restriction.
5. To receive an accounting of disclosures (those with whom we've shared your information).
6. To receive a paper copy of the extended detail Notice of Privacy Practices.
7. To choose someone to act for you. If you have given someone medical power of attorney or if someone Is your legal guardian, that person can exercise your rights and make choices about your health information.
8. To file a complaint if you feel your rights are violated

USES AND DISCLOSURES:
1. Treatment purposes - use your health information and share it with other health care providers who are treating you.
2. Run our organization· use and share your health information to run our practice, improve your care, and contact you when necessary.
3. Bill for your services - use and share your health information to bill and get payment from health plans or other entities.
4. Inadvertent disclosures- an open treating area means open discussion. If you need to speak privately with the doctor, please let our staff know so we can place you in a private room.
5. Help with public health and safety issues· in order to prevent or lessen a serious or eminent threat to the health or safety of a person or general public.
6. For health research purposes.
7. Comply with the law· share information about you if state or federal laws require It, including with the Department of Health and Human Services if it wants to see that we're complying with federal privacy law.
8. Work with a medical examiner or funeral director - share health information with a coroner, medical examiner, or funeral director in the event of a patient's death.
9. For workers' compensation claims, law enforcement purposes or with a law enforcement official, and other government requests - including health oversight agencies for activities authorized by law, special government functions such as military, national security, and presidential protective services.
10. Respond to lawsuits and legal actions - share health information about you in response to a court or administrative order, or in response to a subpoena.
11. Emergency- In the event of a medical emergency we may notify a family member.
12. Phone calls and/or emails-we may call your home and leave messages regarding appointment reminders or apprise you of changes in practice hours or upcoming events.
13. Change of ownership - in the event this practice is sold your health information will become the property of the new owner. You maintain the right to request copies of your health information be transferred to another provider.

COMPLAINT:
If you wish to make a complaint about how we handle your health information, please contact our privacy official using the information noted above. If you are still not satisfied with the manner in which this office handles your complaint, you can submit a formal complaint to:

U.S. Dept. of Health and Human Services, Office of Civil Rights
200 Independence Avenue, SW, Washington DC 20201
877-696-6775
www.hhs.gov/ocr/privacy/hipaa/complaints/

I hereby acknowledge I have read and received a copy of Nob Hill Family Chiropractic Privacy Practices Notice.

I understand my rights as well as the practice's 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 Practices" at any time in the future and will make the new provisions effective for all information that it maintains past and present.

I am aware the practice will not use or share my Information other than as described here unless I have provided written authorization stating otherwise. I understand I may change my mind at any time by providing written notification to the practice.

I am aware an extended detail 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.

HIPAA Personal Health Information Release

I understand I may terminate this consent at any time by giving written notice to Nob Hill Family Chiropractic. Any changes to this form will require a new consent form to be completed, signed, and dated.

To make payment of all benefits for chiropractic and other services rendered to mat at this clinic for all dates and services covered under my policy directly to:

Michael J. Cohen, D.C. P.A.

1848 N Nob Hill Road

Plantation, FL, 33322

I also authorize any holder of medical and chiropractic information about me to release to the healthcare financing administration or insurance adjusters/agents, any information required to determine these benefits for related services. Any other requests for records from this office must be accompanied by a duly executed Authorization for Release of Any Protected Health Information (PHI).
Authorization is hereby granted for my insurance carrier to release any policy and benefit information that is requested by the above named provider of services.
I do agree to· pay directly to this clinic, keeping all accounts current, any and all balances for professional services rendered over and above any insurance payment. This agreement is valid for all services from this date forward, unless other written arrangements are made.
If my current policy prohibits direct payment to the provider of service, I hereby authorize you to make the check payable to me and mail.is _as follows:

c/o Michel J. Cohen, D.C. P.A.
1848 N Nob Hill Road
Plantation, FL, 33322

This is a direct assignment of my rights and benefits under this policy.
A photocopy of this Assignment shall be considered as effective and valid as the original.

Review of Systems

Please mark Y for Yes and N for No

General

Skin

Breast

Head

Respiratory

Neck

Cardiovascular

Gastrointestinal

Psychiatric

Musculoskeletal

Neurological

Endocrine

Hematology

DOCTOR'S LIEN

RE: Patient records and Doctor's Lien

I do hereby authorize the above doctor to furnish you, my attorney/insurance carrier, with a full report of his case history; examination, diagnosis, treatment and prognosis of myself in regard to my accident/illness which occurred/began on

I hereby give a lien to said doctor on any settlement, claim, judgment, or verdict a a result of said accident/illness, and authorize and direct you, my attorney/insurance carrier, to pay directly to said doctor such sums as may be due and owing him for service rendered me, and to withhold such sums from such settlements, claim judgment, or verdict as may be necessary to protect said doctor adequately.

I fully understand that I am directly and fully responsible to said doctor for all chiropractic bills submitted by him for service rendered, and that this agreement is made solely for said doctor's additional protection and in consideration of his awaiting payment. And I further understand that such payment is not contingent on any settlement, claim, judgment, or verdict by which I may eventually recover said fee.

The undersigned, being attorney of record or representative of insurance carrier for the above patient does hereby acknowledge receipt of the above lien, and does agree to honor the same to protect adequately said above named doctor.

APPLICATION FOR FLORIDA "NO-FAULT" BENEFITS

TO ENABLE US TO DETERMINE IF YOU ARE ENTITLED TO BENEFITS UNDER THE FLORIDA PERSONAL INJURY PROTECTION LAW, PLEASE COMPLETE AND RETURN THIS FORM PROMPTLY

COMPLETE THE FOLLOWING INFORMATION CONCERNING YOUR PRESENT EMPLOYER(S):

COMPLETE THE FOLLOWING INFORMATION CONCERNING RESIDENTS IN YOUR HOUSEHOLD:

In the date of the accident the following vehicles were owned by either myself or the above listed person(s). Complete description of motor vehicle  including Tag and/or Vin#

My person who knowingly and with intent to injure, defraud, or deceive any insurance company by filing a statement or claim containing false, 1complete, or misleading information is guilty of a felony of the third degree.

HEREBY AUTHORIZE RELEASE OF MEDICAL INFORMATION INCLUDING, BUT NOT LIMITED TO, MEDICAL BILLS AND REPORTS TO SUCH PERSONS AS THE COMPANY MAY DEEM NECESSARY TO PERFECT ITS RIGHTS OF RECOVERY UNDER THE "NO FAULT" INSURANCE LAW.

AUTOMOBILE ACCIDENT INFORMATION

Please print clearly. This information is needed to properly process your claim.

Standard Disclosure and Acknowledgement Form

Personal Injury Protection - Initial Treatment or Service Provided

The undersigned insured person ( or guardian of such person) affirms:
1. The services or treatment set forth below were actually rendered. This means that those services have already been provided.

2. I have the right and the duty to confirm that the services have already been provided.

3. I was not solicited by any person to seek any services from the medical provider of the services described above.

4. The medical provider has explained the services to me for which payment is being claimed.

5. If I notify the insurer in writing of a billing error, I may be entitled to a portion of any reduction in the amounts paid by my motor vehicle insurer. If entitled, my share would be at least 20% of the amount of the reduction, up to $500.

Insured Person (patient receiving treatment or services) or Guardian of Insured Person:

The undersigned licensed medical professional or medical director, if applicable, affirms the statement numbered I above and also:

A. I have not solicited or caused the insured person, who was involved in a motor vehicle accident, to be solicited to make a claim for Personal Injury Protection benefits.

B. The treatment or services rendered were explained to the insured person, or his or her guardian, sufficiently for that person to sign this form with informed consent.

C. The accompanying statement or bill is properly completed in all material provisions and all relevant information has been provided therein. This means that each request for information has been responded to truthfully, accurately, and in a substantially complete manner.

D. The coding of procedures on the accompanying statement or bill is proper. This means that no service has been upcoded, unbundled, or constitutes an invalid or not medically necessary diagnostic test as defined by Section 627.732(14) and (15), Florida Statutes or Section 627.736(5)(b)6, Florida Statutes.

Licensed Medical Professional Rendering Treatmen1/Services or Medical Director, if applicable (Signature by his/ her own hand):

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of Claim or an application containing any false, incomplete; or misleading information is guilty of a felony of the third degree per Section 817.234(l)(b), Florida Statutes

Note: The original of this form must be furnished to the insurer pursuant to Section 627.736(4)(b), Florida Statutes and may not be electronically furnished. Failure to furnish this form may result in non-payment of the claim.