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Dr. Travis Lamperski - Chiropractic Physician 5500 S. Stated Rd 7, Suite 112 Lake Worth, FL 33449
Phone: (561) 708-5700 / Fax: (561) 708-5750 www.ChiroPalmBeach.com / [email protected]
WELCOME TO OUR OFFICE
We specialize in assisting our patients to achieve their
highest level of health through our evidenced-based treatment
protocol. Our approach is very unique and advanced from other
chiropractic office programs. This allows our patients to
achieve far superior results compared to most other systems.
Please fill out the following information thoroughly so the
doctor can let you know if you are a case we can accept. Please
feel free to ask any questions if you need assistance. We look
forward to serving you.
Dr. Travis Lamperski - Chiropractic Physician 5500 S. Stated Rd 7, Suite 112 Lake Worth, FL 33449
Phone: (561) 708-5700 / Fax: (561) 708-5750 www.ChiroPalmBeach.com / [email protected]
New Patient Information
Name:___________________________________________________________________________
Date of Birth:____________________________
Home phone:_____________________________ Work phone: ___________________________
Cell phone: _____________________________
Address:__________________________________________________________________________
City, St, Zip_______________________________________________________________________
What is your Native Language?______________________________________________________
Emergency contact/Relationship ____________________phone____________________________
Email: (Please print clearly.)_________________________________________________________
Occupation:_______________________________________________________________________
Who is your primary care physician? _________________________________________________
May we have permission to contact your physician regarding your case? ( ) Yes ( ) No
How did you hear about us? _________________________________________________________
Have you ever been to a Chiropractor before? ( ) Yes ( ) No.
I give Palm Beach Chiropractic & Rehabilitation, Inc. and its representative’s permission to communicate
to me via the contact information above.
___________________________________________________ _____________________
Signature Date
** Standard Assignment and Release **
I assign and authorize my insurance benefits to be paid directly to Palm Beach Chiropractic &
Rehabilitation. I understand that I am financially responsible for any balance incurred for services
rendered, except in the case of worker’s compensation and contractual write-offs. I waive any statutory
time limitations for collecting any amount due and authorize Palm Beach Chiropractic & Rehabilitation to
release any information necessary to process my claims.
___________________________________________________ _____________________
Signature of Insured Date
Dr. Travis Lamperski - Chiropractic Physician 5500 S. Stated Rd 7, Suite 112 Lake Worth, FL 33449
Phone: (561) 708-5700 / Fax: (561) 708-5750 www.ChiroPalmBeach.com / [email protected]
Informed Consent for Chiropractic Treatment
All medical procedures have potential side effects and complications. While the risk of serious
complication resulting from the procedures utilized in this office is extremely small, we feel it is
important for you to be fully informed prior to proceeding with our care.
Prior to any treatment being provided in this office a physical examination will be undertaken in which
your body will be moved in different directions to determine where the pain is coming from. This can
result in residual pain or soreness.
The primary treatments used by the chiropractic physicians in this office are various types of manual
techniques (manipulation, mobilization) and various types of exercise. In approximately 1/3 of patients
who are treated with manipulation, increased pain results, usually after the first or second treatment.
This is mild or moderate in 90% of cases and almost always resolves within 48 hours. In rare cases, rib
fractures have been known to occur. No treatment will be provided until an examination is performed,
a diagnosis is made and a discussion of our findings and recommendations is undertaken.
There are rare reported cases of disc injuries identified following manipulation, although no scientific
evidence has demonstrated such injuries are caused, or may be caused, by manipulation. However,
there are uncommon cases in which a pre-existing disc herniation may become aggravated.
There are reported cases of stroke associated with visits to both medical physicians and chiropractic
physicians. Research and scientific evidence does not establish a cause and effect relationship between
manipulation and the occurrence of stroke. Recent studies suggest that patients may be consulting
medical doctors and chiropractors when they are in the early stages of a stroke. In essence, there is a
stroke already in progress. However, you are being informed of this reported association because a
stroke may cause serious neurological impairment or even death. The possibility of such injuries
occurring in association with upper cervical manipulation is extremely remote.
Other treatment options outside this office may include, over-the-counter analgesics and rest, medical
care and prescription drugs such as anti-inflammatory, muscle relaxants and pain-killers, injections or
surgery.
If you chose to use one of the above noted “other treatment” options, you should be aware that there
are risks and benefits of such options and you may wish to discuss these with your primary medical
physician.
Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a
pain reaction further reducing mobility. Over time this process may complicate treatment making it
more difficult and less effective the longer it is postponed.
By signing below I state that I have weighed the risks involved in undergoing treatment and have
decided that it is in my best interest to undergo the treatment recommended. Having been informed of
the risks, I hereby give my consent to that treatment.
Signature:_______________________________________________________ Date: ____/____/____
Dr. Travis Lamperski - Chiropractic Physician 5500 S. Stated Rd 7, Suite 112 Lake Worth, FL 33449
Phone: (561) 708-5700 / Fax: (561) 708-5750 www.ChiroPalmBeach.com / [email protected]
PATIENT CONSENT FORM
(HIPAA)
I understand that I have certain rights to privacy regarding my protected health information. These rights
are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I
understand that by signing this consent I authorize you to use and disclose my protected health
information to carry out:
Treatment (including direct or indirect treatment by other healthcare providers involved in my
treatment)
Obtaining payment from third party payers (e.g. my insurance company)
The day to day healthcare operations of your practice
I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy
Practices, which contains a more complete description of the uses and disclosures of my protected health
information, and my rights under HIPAA. I understand that you reserve the right to change the terms of
this notice from time to time and that I may contact you at any time to obtain the most current copy of this
notice.
I understand that I have the right to request restrictions on how my protected health information is used
and disclosed to carry out treatment, payment, and health care operations, but that you are not required to
agree to these requested restrictions.
However, if you do agree, you are then bound to comply with this restriction.
I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that
occurred prior to the date I revoke this consent is not affected.
Date:________________________________________
Print Patient Name: _____________________________
Relationship to Patient: __________________________
Signature: ____________________________________
Dr. Travis Lamperski - Chiropractic Physician 5500 S. Stated Rd 7, Suite 112 Lake Worth, FL 33449
Phone: (561) 708-5700 / Fax: (561) 708-5750 www.ChiroPalmBeach.com / [email protected]
Travis Lamperski, D.C.
Power of Attorney and Medical Release
POWER OF ATTORNEY TO ENDORSE CHECKS AND/OR TO SIGN ANY PIECE OF PAPER WHICH WILL ENHANCE
OR EXPEDITE PAYMENT TO PROVIDER FOR SERVICES REDERED, INCLUDING BUT NOT LIMITED TO A
RELEASE OF MEDICAL RECORDS AND ASSIGNMENT OF BENEFITS/AUTHORIZATION TO PAY.
Know by all these present that: The undersigned has made, constituted and appointed, and by these presents does hereby make,
constitute and appoint TRAVIS LAMPERSKI, D.C., and any of its duly authorized agents and employees as and to be the
undersigned’s true and lawful attorney for and in the undersigned’s name place and stead to endorse any and all checks, drafts or
money orders which are made payable to the undersigned alone or to the undersigned and the said TRAVIS LAMPERSKI, D.C.,
which checks, drafts or money orders are made payable for services which have been made by TRAVIS LAMPERSKI, D.C., at
the request or with the knowledge and approval for the undersigned and or the maker of the check, draft of money order.
Furthermore, the undersigned allows TRAVIS LAMPERSKI, D.C., or any of its agents to sign any paper that will be necessary
to enhance, expedite and/or allow payment to said provider. This may include affidavits of non-ownership of vehicles, insurance
forms and other statements.
The undersigned by these presents does give and grant the said TRAVIS LAMPERSKI, D.C., as attorney the full power and
authority to do and perform all and every act whatsoever requisite and necessary to be done in and about the premises as fully to
all intents and purposes as the undersigned might or could do to personally present insofar as the endorsing and cashing of said
checks are concerned as well as any other document.
Medical Release
A photocopy of this document shall be sufficient to authorize any person having records of medical treatment, services or
supplies pertaining to me to release true copies of the same to TRAVIS LAMPERSKI, D.C., or any insurer providing coverage to
me in connection with the processing of any claim for benefits made by me or by the assigned herein. A photocopy of this
document shall be as binding as an original signature page.
The undersigned does hereby ratify and confirm any and all actions taken by the said attorney in accordance with this special
power and which the said attorney shall do or cause to be done by virtue of these presents.
Assignment of Benefits
I, ___________________________________ Hereby authorize, __________________________________________________
(Name of Insured Patient) (Name of Insurance Carrier)
to make medical payments otherwise payable to me for services rendered by TRAVIS LAMPERSKI, D.C., but not to exceed the
charges of those services, payable to and mailed directly to:
TRAVIS LAMPERSKI, D.C.
5500 S. STATED RD. 7 SUITE 112
LAKE WORTH, FL 33449
Furthermore, I HEREBY IRREVOCABLY assign to TRAVIS LAMPERSKI, D.C., the rights and benefits under any policy of
insurance, indemnity agreement, or any other collateral source as defined in Florida Statues for any service and/or charges
provided by TRAVIS LAMPERSKI, D.C.
IN WITNES WHEREOF the undersigned have hereunto set their hands, this ____________ day of ______________,20____
_________________________________ ____________________________________
PATIENT SIGNATURE PATIENT’S NAME (Please Print)
Dr. Travis Lamperski - Chiropractic Physician 5500 S. Stated Rd 7, Suite 112 Lake Worth, FL 33449
Phone: (561) 708-5700 / Fax: (561) 708-5750 www.ChiroPalmBeach.com / [email protected]
Personal Injury Questionnaire (Auto Accident)
Name:__________________________________________ Date (today):___________________
Have you filed a claim with the insurance company? NO YES Claim #:________________
Date of Accident:_____________ Where did the accident happen? Describe in your own words:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
What was your position in the car?
Driver: Were your hands on the steering wheel? Left Right Both
Passenger: Where were you seated? Front Right Rear Left Rear?
Did your vehicle strike another vehicle? NO YES
Angles of impact….First Impact: Front Rear Left Right
Second Impact: Front Rear Left Right
Were you wearing your seatbelt? NO YES
Did you brace for impact? NO YES I braced with my hands I braced with my feet
Which way were you facing at the time of impact? Straight ahead Left Right
Did YOU strike anything in the vehicle at the time of impact? NO YES
If YES, specify what part of your body struck what: ie… head, chest, shoulder/knee right/left
Steering Wheel_____________________ Dashboard____________________________
Windshield_________________________ Roof_________________________________
Left Side Door______________________ Right Side Door _______________________
Left Window_______________________ Right Window_________________________
Other______________________________________________________________________
Did the seat back bend / break? NO YES
Immediately following the accident. How did you feel? dizzy/dazed disoriented
nervous nauseous upset weak other________________________
Did you lose consciousness? NO YES
Did you go to the hospital? NO YES Were you admitted? NO YES
If YES, how long?______________
If you went to the hospital, when? At time of accident Next day
How did you get to the hospital? Ambulance Police car Private Transportation
Name of hospital:_______________________________________________________________
Attended by Dr. ________________________________________________________________
Have you seen any other doctor as a result of this accident? NO YES
Who?________________________________________________________________________
Dr. Travis Lamperski - Chiropractic Physician 5500 S. Stated Rd 7, Suite 112 Lake Worth, FL 33449
Phone: (561) 708-5700 / Fax: (561) 708-5750 www.ChiroPalmBeach.com / [email protected]
What treatment was given?
None placed in a brace X-ray/MRI/CT: ________ given stretches bandaged
given pain medication given instructions regarding concussion physical therapy
given instructions regarding sprain & strain referred to orthopedic surgeon / PCP
referred to this office for treatment Other____________________________________
CHIEF Complaints or Symptoms:
Neck Pain, with pain radiating into: none left shoulder left arm left forearm
left hand right shoulder right arm right forearm right hand
YOU are also experiencing: Headache Migraine Headache Upper back pain
Ringing in the ears: NO YES Left Right Both Ears
Blurry Vision: NO YES Left Right Both Eyes
Wrist Pain: NO YES Left Right Both Wrists
Jaw Pain: NO YES Left Right Both Sides
dizziness nervousness fatigue anxiety depression excessive irritability
fear of driving in a car a loss of concentration jaw clenching teeth grinding
nightmares difficulty with sleeping at night other:_________________________
Low Back Pain, with pain radiating into: no radiating pain left buttock left thigh
left knee left foot right buttock right thigh right knee right foot
Hip Pain: Left Right Bilateral
Knee Pain: Left Right Bilateral
Foot/Ankle Pain Left Right Bilateral
Numbness: NO YES, Where? _______________________________________________
Tingling: NO YES, Where? _______________________________________________
Additional Symptoms / Complaints: ________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Have you lost any time at work due to your injuries? NO YES Dates:_______to_______
Have you had any previous injuries or accidents? NO YES
Description of Accident/Injuries:___________________________________________________
How much better did you feel prior to your current condition? (Ex: 100%, 80% etc):_________%
I give Palm Beach Chiropractic & Rehabilitation, Inc. and its representative’s permission to
communicate to me via the contact information provided.
Signature:__________________________________________ Date: _____________________
Dr. Travis Lamperski - Chiropractic Physician 5500 S. Stated Rd 7, Suite 112 Lake Worth, FL 33449
Phone: (561) 708-5700 / Fax: (561) 708-5750 www.ChiroPalmBeach.com / [email protected]
Authorization for release of healthcare provider medical records and billing information.
Patients Name______________________________ Phone # _______________________
Date of Birth ______________________________
I hereby authorize Palm Beach Chiropractic & Rehabilitation, Inc. to disclose the following health
information to:
Name: __________________________________________
Phone # __________________Fax #___________________
Address:____________________________________________________________________________
I hereby authorize (name & phone #)____________________________________________________
to disclose the following health information to Palm Beach Chiropractic & Rehabilitation, 5500 S.
State Rd. 7 Suite 112, Lake Worth FL 33449. Phone (561) 708-5700 Fax (561) 708-5750
E-mail: [email protected] (E-mail X-RAYS and Records if possible please)
Information to be released must be checked: (please be specific)
_____ the entire medical record _____ follow-up/progress notes
_____ history and physical _____ referral letters and consults
_____ operative notes _____ admission/discharge summary
_____ MRI, X-ray, lab reports, etc _____ billing statements
_____ physical therapy notes _____ other ____________________
For dates of service: _______________________________________________________
To the extent applicable, I understand that my medical record may contain information that is considered
sensitive in nature under the law. My check marks below indicate(s) that I do NOT permit
information of this type, if it exists, to be released. If I do not check any boxes all such information will
be released.
HIV/AIDS Sexually Transmitted Diseases Treatment for Drug and/or Alcohol
I understand that this authorization will expire one year from the date of signing unless a shorter time
period is indicated. I understand that I may revoke this authorization at any time by writing to the medical
provider identified above. Revocation will not apply to information already disclosed.
I understand that my records are protected under federal privacy laws and regulations under state law, and
cannot be disclosed without written consent except as otherwise specifically provided by law.
Form must be fully completed before signing.
____________________________________________________ _______________
Signature of Patient or Legal Representative (attach power of attorney) date
_____________________________________________________
Signers Name and Relationship if not patient
OFFICE OF INSURANCE REGULATION Bureau of Property & Casualty Forms and Rates
OIR-B1-1571 Pub. 1/2004
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:
Name (PRINT or TYPE) Signature Date
The undersigned licensed medical professional or medical director, if applicable, affirms the statement numbered 1 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 Treatment/Services or Medical Director, if applicable (Signature by his/ her own hand):
Name (PRINT or TYPE) Signature Date
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(1)(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.