Post on 16-Aug-2020
Munday Chiropractic Clinic, P.A.
Today’s Date: ____________________ Email:___________________________ Name: ________________________ DOB: _______ Sex: M F Last 4 #’s of SS#: _______
Address ____________________________________________City _________________State _____ Zip ________ Phone #’s: Cell: __________________ Home: ________________ Work: ________________
Employer __________________Occupation ______________Address ______________________ Ph ___________
Spouse __________Employer _________ Emergency Contact_______________Ph__________Relation__________
HEALTH INSURANCE INFORMATION: Your PRIMARY insurance Co____________________ Policyholder’s name &
DOB_______________________ Policyholder’s relation to patient_________ Policyholder’s employer __________
ACCIDENT INFORMATION : Auto Work Slip & Fall *Date and place of injury _____________________________
Auto/work insurance Co.____________________ Insured’s Name and DOB ________________________________
Accident reported to your insurance Co or Boss? Yes No, Claim# _____________________ Please provide dates
and details of ALL prior accidents_________________________________________________________________
HISTORY of 1st COMPLAINT: Where is your WORST symptom:_______________________________________________
How long have you had it: _____________________ How did it start: ______________________________________
Is it: Improving or Worsening or Staying the Same Is it: Mild or Moderate or Severe
What WORSENS it: Activity Moving wrong Bending Lifting Walking Sports Getting up from a chair
Using a computer and/or deskwork Performing your work duties Other:__________________________________
What IMPROVES it: Rest Activity Ice packs Heating pad Over-the-counter meds Prescription Meds
Massages Past chiropractic care Physical Therapy Other: ____________________________________________
Is it worse in the: Morning time Night Time After day wears on Fairly Steady Off and on with no pattern
Is it: Dull & achy Tight & stiff Sharp and stabbing Numb & tingly Shooting Burning Cramping
HISTORY of 2nd COMPLAINT: Where is your SECOND WORST symptom:___________________________________
How long have you had it: _____________________ How did it start: ______________________________________
Is it: Improving or Worsening or Staying the Same Is it: Mild or Moderate or Severe
What WORSENS it: Activity Moving wrong Bending Lifting Walking Sports Getting up from a chair
Using a computer and/or deskwork Performing your work duties Other:__________________________________
What IMPROVES it: Rest Activity Ice packs Heating pad Over-the-counter meds Prescription Meds
Massages Past chiropractic care Physical Therapy Other: ____________________________________________
Is it worse in the: Morning time Night Time After day wears on Fairly Steady Off and on with no pattern
Is it: Dull & achy Tight & stiff Sharp and stabbing Numb & tingly Shooting Burning Cramping
Medicare Patients ONLY (check ONLY ONE that you would like to be able to do without pain)
___ bend and lift ___read ___get up from sitting ___ get a good night’s sleep ___work at a computer
___do housework ___ do yard work ___ play sporting activities
Page 1
CURRENT HEALTH HISTORY Name, address and ph# of your family doctor___________________________________________________
List all CURRENT illness or disease you are experiencing (such as cancers, tumors, infections, aneurysms,
diabetes, liver/kidney disease) etc: ___________________________________________________________
____________________________________________________ Date of last eye exam: ________________
List Blood Thinners:______________ Please list medication allergies:_______________________________
Please list your Height ________ Weight__________ What is your usual blood pressure ________/________
PAST HEALTH HISTORY Please list past operations, surgeries or medical procedures you have had:
Date:__________Procedure:______________________Date:__________Procedure:___________________
Date:__________Procedure:______________________Date:__________Procedure:___________________
Please list all past or current illnesses, such as cancers, bone tumors, infections, aneurysms, stents, injuries:
Date:__________Condition:______________________Date:__________Condition:___________________
Date:__________Condition:______________________Date:__________Condition:___________________
Recent loss of bowel/bladder control: Y N Recent seizures, paralysis, speech or vision problems: Y N
Any unexplained recent weight loss: Y N Current fever: Y N
List any blood or lymph node disorders ________________________
Do you have osteoporosis: Y N List any skin, hair or nail disorders _______________________________
Do you have a Pacemaker or other electric device that you currently wear? Y N If yes, please Alert us NOW
Circle ONE: I never smoked Former smoker Current smoker, if so how much: __ pack/day or __pack/wk
Circle ONE: I don’t drink any alcohol Rarely drink Social/moderate drinker Heavy drinker: (___oz/day/wk)
Have you ever had Chiropractic care? Y N If yes, last date of treatment ________Date of x-rays:__________
By whom? Dr. _____________Similar or Different condition?_______________Results _________________
What are your overall expectations from your visit/treatment with Dr. Munday? _________________________
__________________________________________________________________________________________ I, the undersigned, hereby give my consent for the Doctor to examine and treat my condition as he deems appropriate through the
use of Chiropractic and/or massage therapy care. I give my consent to the Doctor to take x-rays (if needed) or to perform other
diagnostic aids as deemed appropriate in my case. I also understand that treatment may result in temporary bruising, increased
pain or discomfort, and/or aggravation of symptoms.
Women Only: I hereby declare that to the best of my knowledge, ___I am or ___I am not pregnant. If there is a chance that I
may be pregnant, I will inform the Staff and/or Doctor prior to my examination.
Patient's Signature _______________________________________________________________ (Parent/Guardian signature if patient is under 18 years of age)
Page 2
GENERAL/FINANCIAL POLICY
Welcome to Munday Chiropractic Clinic, P.A. We strive to provide you with excellent Chiropractic care in a clean, friendly, professional setting.
By signing below, you confirm that you have read this policy and understand that:
It is your responsibility to inform our office of any address or telephone number changes.
Your account is to be kept current. All self pay, insurance copayments, co-insurances and deductibles will be collected at the time of service payable by cash, check, or credit card. For your convenience, we can store your credit card on file.
If you are unable to keep a massage appointment, please notify us 24 hours before your appointment so that we may offer that time to another patient. We will try to fill your missed spot with another patient, but in the event that we are unable to do so, there is a $20 fee for missing a 30 minute massage, a $30 fee for missing a 45 minute massage, and a $40 fee for missing a 60 minute massage without a 24 hour notice. If a massage is missed without proper notification, all future massage appointments must be secured with a credit card on file. In the event you miss any future massages without proper notice, you agree for us to charge your card the missed fee. Initial here: ______
If you have a Health Savings Account that pays for your services when the claim is submitted, you must secure a credit card on file. In the event your fund is depleted when we submit our claim, the unpaid balance will then be settled with your credit card we have on file. We will call you to inform you of such charge. Initial here: ______
If you believe that your deductible has been met, even after we verify with your health insurance company that it is not yet met, you will be required to pay for your services at the time of your visit. In the event that our claim is paid, you will have a credit on your account. Initial here: ______
Returned checks will result in a $25.00 service fee and all future payments will be in the form of cash or credit card.
You will only be sent a statement if your balance exceeds $10.00.
There is a $15 charge for the completion of paperwork such as Disability Forms and FMLA forms.
If your account is turned over to a collection agency, you will be responsible for any costs incurred in collection of funds.
IF YOU HAVE HEALTH INSURANCE COVERAGE: As a courtesy to you, our office will attempt to pre-verify your primary insurance coverage for your Chiropractic care. Coverage information is obtained from your insurance company using information provided by you prior to your initial visit. We must emphasize that as medical providers, our relationship is with you, not your insurance company. Please be advised that the information provided by your insurance company is not a guarantee of payment, only an estimate of what might be covered under your policy at the time of inquiry. You will be responsible for any unpaid amounts.
By signing below you confirm you understand that: It is your responsibility to inform us of any changes to your insurance policy so that your coverage can be re-verified.
Not all services are a covered benefit with all insurance plans. We will do our best to inform you of non-covered services.
It is your responsibility to be aware of what service (s) is being provided to you and if it is a covered benefit under your insurance.
You are responsible for any non-covered services not payable by your insurance policy.
We will send all required claim forms and documentation to ensure your claims are processed in a timely manner.
Final determination of benefits available is determined when the claim is sent to your insurance company and we receive an explanation of benefits from them. After all co-pays, contracted plan reductions and insurance payment credits are applied to your account, any remaining portion will be your responsibility. We will attempt to contact you in order to collect any unpaid amounts on your account, but if we are unable to contact you or we have had no response to mailings and/or phone calls, you agree for us to bill your credit card on file for any unpaid amounts. Before billing your card, we will send a letter to the address we have on file informing
you that we will bill your card within 14 days of mailing. By initialing here you agree to this policy. Initial here: ______
If you are a MEDICARE PATIENT, please be advised that Medicare only covers Spinal Adjustments in a Chiropractor’s office. All services other than the Spinal Adjustment will be your financial responsibility.
By signing below, you have read and understand the above Financial Policy and agree to meet all financial obligations. ________________________________________ ____________________________________________ ________________ Printed Name Signature of Patient/Legal Guardian Date CONSENT TO RELEASE INFORMATION: In the event that you ever wish to have a family member/friend come to our office and get a copy of your medical records for whatever reason, we ask that you sign below allowing them to do so. ________________________________________ ____________________________________________ ________________ Name of Family Member/Friend Signature of Patient/Parent/Legal guardian Date CONSENT TO TREAT A MINOR: I hereby authorize and give consent for the Chiropractic Physicians at Munday Chiropractic Clinic to examine, and if needed, treat my minor child _____________________________________________.
Print child’s name here ________________________________________ ____________________________________________ ________________ Printed Name of Parent/Legal Guardian Signature of Parent/Legal Guardian Date
MUNDAY CHIROPRACTIC CLINIC, P.A.
Patient Consent for Use and Disclosure
of Protected Health Information
I hereby give my consent for Munday Chiropractic Clinic, P.A. to use and disclose
protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO).
(The Notice of Privacy Practices provided by Munday Chiropractic Clinic, P.A. describes such uses and
disclosures more completely.)
I have the right to review the Notice of Privacy Practices prior to signing this consent. Munday Chiropractic
Clinic, P.A. reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy
Practices may be obtained by forwarding a written request to:
Munday Chiropractic Clinic, P.A.
6645 N. Socrum Loop Rd,
Lakeland, Fl 33809
(863) 853-3000
With this consent, Munday Chiropractic Clinic, P.A. may call my home, mobile phone, or other alternative
locations and leave a message on voice mail or in person in reference to any items that assist the practice in
carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care,
including laboratory test results, among others.
With this consent, Munday Chiropractic Clinic, P.A. may mail to my home or other alternative locations any
items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as
long as they are marked “Personal and Confidential.”
With this consent, Munday Chiropractic Clinic, P.A may e-mail my home or other alternative locations or text
to my mobile phone any items that assist the practice in carrying out TPO, such as appointment reminders,
portal log-in requests, and patient statements. I have the right to request that Munday Chiropractic Clinic, P.A.
restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested
restrictions, but if it does, it is bound by this agreement.
By signing this form, I am consenting to allow Munday Chiropractic Clinic, P.A. to use and disclose my PHI to
carry out TPO.
I may revoke my consent in writing except to the extent that the practice has already made disclosures in
reliance upon my prior consent. If I do not sign this consent, or later revoke it, Munday Chiropractic Clinic,
P.A. may decline to provide treatment to me.
_______________________________
Signature of Patient or Legal Guardian
_______________________________ ______________________
Print Patient’s Name Date