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Powell Chiropractic Clinic, Inc. Phone: (330) 494-5533 4867 Munson Street, NW Fax: (330) 494-8101 Canton, OH 44718 www.powellchiropractic.com

Powell Chiropractic Clinic, Inc. 4867 Munson St NW Canton, OH 44718 330-494-5533

(Office use only) Acct Number ______________________

NEW PATIENT INFORMATION

FIRST _________________________________ MI__________LAST__________________________________

How did you hear about our office? _________________________________________________________________

Address __________________________________City ___________________State_______ Zip___________

Home Phone: _______________________________ Cell Phone:______________________________

DOB: ____________________Social Security Number (used for billing purposes): ________________________

Email_____________________________________________________________________________________

Employer: ________________________________Employer Phone: __________________________________

If Patient is a Minor: PARENT’S NAME __________________________________________________________

Person(s) to contact in case of emergency, questions concerning my treatment, and any questions concerning

any account or account balance.

Name ________________________________________ Telephone_______________________________

Relationship___________________________________ Cell Phone: ______________________________

Please Initial:

I give permission to leave a message on my home or cell phone: Yes_________ No_________

I give permission to leave a detailed message on my home or cell: Yes_________ No_________

I give permission to be contacted by text message: Yes_________ No_________

I acknowledge that the information listed above is true to my knowledge and if there are any changes, I

understand that it is my responsibility to contact the office.

Print Full Name: _________________________________________________ Date: __________________

Signature: ______________________________________________________Date: ___________________


LEGAL ASSIGNMENT OF BENEFITS AND RELEASE OF MEDICAL AND PLAN DOCUMENTS

In considering the amount of medical expenses to be incurred, I, the undersigned, have insurance and/or employee health care benefits coverage with the above captioned, and hereby assign and convey directly to Powell Chiropractic Clinic all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for services rendered from such doctor and clinic. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize the doctor to release all medical information necessary to process this claim. I hereby authorize any plan administrator or fiduciary, insurer and my attorney to release to such doctor and clinic any and all plan documents, insurance policy and/or settlement information upon written request from such doctor and clinic in order to claim such medical benefits, reimbursement or any applicable remedies. I authorize the use of this signature on all my insurance and/or employee health benefits claim submissions. I hereby convey to the above named doctor and clinic to the full extent permissible under the law and under the any applicable insurance policies and/or employee health care plan any claim, chose in action, or other right I may have to such insurance and/or employee health care benefits coverage under any applicable insurance policies and/or employee health care plan with respect to medical expenses incurred as a result of the medical services I received from the above named doctor and clinic and to the extent permissible under the law to claim such medical benefits, insurance reimbursement and any applicable remedies. Further, in response to any reasonable request for cooperation, I agree to cooperate with such doctor and clinic in any attempts by such doctor and clinic to pursue such claim, chose in action or right against my insurers and/or employee health care plan, including, if necessary, bring suit with such doctor and clinic against such insurers and/or employee health care plan in my name but at such doctor and clinic's expenses. Should this assignment be prohibited in part or in whole under any anti-assignment provision of my policy/plan, please advise and disclose to my provider in writing such anti-assignment provision within 30 days upon receipt of my assignment, otherwise this assignment should be reasonably expected to be effective and such anti-assignment is waived. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I have read and fully understand this agreement. Patient Signature _____________________________________ Date _______/_______/_______ _________________________________________________________________________________________

Dr. James P. Powell · Dr. James D. Powell · Dr. Robert Powell · Dr. Walter B. Null IV · Dr. Abbey M. Crouse

Powell Chiropractic Clinic, Inc.


PRACTICE’S REQUIREMENTS The Practice:

(a) Is required by federal law to maintain the privacy of your Personal Health Information (PHI) and to provide

you with this Privacy Notice detailing the Practice’s legal duties and privacy practices with respect to your

PHI.

(b) Powell Chiropractic Clinic, Inc. adheres to Ohio law in those instances where Ohio law does not conflict with

Federal law.

(c) Is required to abide by the terms of this Privacy Notice.

(d) Reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice provisions

effective for all of your PHI that it maintains.

(e) Will distribute any revised Privacy Notice to you prior to implementation.

(f) Will not retaliate against you for filing a complaint.

EFFECTIVE DATE

This Notice is in effect as of 04/15/03. If you would like to review our HIPPA agreement, please advise our staff and we will supply you with detailed information.

PATIENT ACKNOWLEDGEMENT

By signing below, I acknowledge that I have read this Notice, and that I understand and agree to its terms.

Patient Name

Patient Signature

Date




MEDICATION/SUPPLEMENT UPDATE

We are in the process of updating our records to comply with federal standards, please answer the following questions:

Patient: _____ Date: ________________ Last Name First Name Initial

Do you take vitamins or other supplements?

Not currently taking any vitamins or supplements

Yes… What? ______________________________ _______ mg or times/day

What? ______________________________ _______ mg or times/day

What? ______________________________ _______ mg or times/day

Have you had recent tests showing high cholesterol and/or triglycerides? Yes No

Have you had recent tests showing high blood pressure? Yes No

Are you diabetic? Yes No Are you taking insulin? Yes No

Do you eat breakfast daily? Yes No

How many days/week do you skip one or more meals? 0-1 2-3 4 or more

How many servings of vegetables do you eat/day (average)? 0-1 2-3 4 or more

How many servings of fruit do you eat/day (average)? 0-1 2-3 4 or more

How many times do you eat fast-food or refined/processed foods a week (average)?

0-2 3-5 6-8 9 or more

What are your average hours of sleep/night?

0-3 4-5 6-7 8 or more

Do you need to take pills to sleep or be able to relax? Yes No

Have you received the full, standard profile of vaccinations? Yes No

Have you had the flu shot this year? Yes No

Have you had flu shots in the past? Yes No


AUTO INSURANCE VERIFICATION FORM NAME___________________________________________________________________________________ APPOINTMENT DATE_____________________________ POWELL ACCT #___________________________

AS PREVIOUSLY EXPLAINED, OUR OFFICE POLICY IS TO BILL YOUR AUTO INSURANCE THROUGH THE MEDICAL PAYMENTS CLAUSE IN YOUR POLICY.

YOU MUST PROVIDE US WITH THE FOLLOWING INFORMATION

BEFORE BEING SEEN AT THE OFFICE

1. DATE OF ACCIDENT_______________________________________________________________

2. YOUR AUTO INSURANCE INFORMATION:

a. COMPANY NAME___________________________________________________________

b. ADJUSTER NAME___________________________________________________________

c. INSURANCE MAILING ADDRESS FOR CLAIM _____________________________________

_________________________________________________________________________

d. INSURANCE PHONE#__________________________FAX #_________________________

e. POLICY #____________________________CLAIM # ______________________________

f. AUTO MED AMOUNT _______________________________________________________

3. RESPONSIBLE PARTY AUTO INSURANCE INFORMATION:

a. COMPANY NAME___________________________________________________________

b. ADJUSTER NAME___________________________________________________________

c. INSURANCE MAILING ADDRESS FOR CLAIM _____________________________________

_________________________________________________________________________

d. INSURANCE PHONE#__________________________FAX #_________________________

e. POLICY #____________________________CLAIM # ______________________________


ASSIGNMENT AND AUTHORIZATION PRIVATE AND GROUP ACCIDENT AND HEALTH INSURANCE

(YOUR INSURANCE/AUTOMED INFORMATION)

I hereby request to pay directly to POWELL

CHIROPRACTIC CLINIC, INC., 4867 Munson Street, NW, Canton, Ohio 44718 the TOTAL AMOUNT OF

MEDICAL CHARGES payable under the terms of Claim Number ____________________, Policy Number

______________________ on account of claim commencing on or about ___________________________.

I specifically authorize that this assignment may be paid from disability benefits, medical payments, or from ANY benefits due to me under this claim. I understand and agree that any unpaid balances not covered by this policy will be paid by me. I also authorize the above named Doctor/Clinic to release any information, pertinent to my case, to any insurance company, adjuster or attorney involved in the case. Dated at Canton, Ohio this ___________ day of ___________________________, 20_______. _________________________________________________ Signature of Policy Holder _________________________________________________ Witness I hereby state and agree that a photocopy of this document will be deemed as valid and binding on all parties involved as the original copy.

Name of Company

Date


ASSIGNMENT AND AUTHORIZATION PRIVATE AND GROUP ACCIDENT AND HEALTH INSURANCE

(RESPONSIBLE PERSON’S INSURANCE INFORMATION)

I hereby request to pay directly to POWELL

CHIROPRACTIC CLINIC, INC., 4867 Munson Street, NW, Canton, Ohio 44718 the TOTAL AMOUNT OF

MEDICAL CHARGES payable under the terms of Claim Number ____________________, Policy Number

______________________ on account of claim commencing on or about ___________________________.

I specifically authorize that this assignment may be paid from disability benefits, medical payments, or from ANY benefits due to me under this claim. I understand and agree that any unpaid balances not covered by this policy will be paid by me. I also authorize the above named Doctor/Clinic to release any information, pertinent to my case, to any insurance company, adjuster or attorney involved in the case. Dated at Canton, Ohio this ___________ day of ___________________________, 20_______. _________________________________________________ Signature of Claimant, if other than Policy Holder _________________________________________________ Witness I hereby state and agree that a photocopy of this document will be deemed as valid and binding on all parties involved as the original copy.

Name of Company

Date


PATIENT VERIFICATION

I have been advised by this Clinic that the preferred method for payment of treatment fees is for the fees to be paid directly by me as I receive treatment:

I do not want my health insurance to be billed for treatment of my injuries, except in the case that my own

liability insurer requires it as a condition to qualifying for medical payments coverage.

I authorize this Clinic to bill my own liability insurer for treatment fees I incur. I authorize this Clinic to send notice of the Assignment to my own liability insurer, to the liability insurer of the person I claim caused my injuries, and to the attorney representing me for My Claim. This document is made a part of the Assignment I have signed in favor of the Clinic. _______________________________________ ___________________________________________ Name of Liability Insurer for Person at Fault Name of My Liability Insurer ____________________________________ Name of My Attorney, if applicable I have received a copy of an Assignment which I have signed in favor of this Clinic and Schedule of Treatment Fees. ______________________________________________ _______________________________ Signature of Patient, Parent, or Legal Guardian Date ______________________________________________ _______________________________ Print or Type Name Staff Witness


PAYMENT FOR TREATMENT (When Patient's Health Insurance Will Not Be Billed)

I have been injured. I do not have health insurance or do not want my health insurance to pay for the treatment fees. If my automobile insurance will cover my treatment fees, I authorize this Clinic to bill this insurer. Even if no other person is at fault for my injuries caused by an accident, agree to sign this Clinic's Assignment and related documents, and will provide any information required by the Clinic. I realize that any money which I receive from my automobile insurer for this Clinic's treatment fees must be immediately paid over to this Clinic. If I believe that one or more persons are at fault for causing my injuries in an accident, I agree to sign this Clinic's Assignment and related documents, and will provide any information required by the Clinic. I understand that my automobile insurer, or an insurer representing someone I believe to be at fault for causing my injuries, or that persons' attorney, or an attorney representing me in a claim for injuries, may request reports, copies of records may require a physician from this Clinic to provide deposition testimony or testimony in court, or other information. I understand and agree that I am financially responsible to this Clinic to pay the Clinic's costs for these items, and that the Clinic may request payment in advance for some or all of these items, even if this Clinic's Assignment states otherwise. I understand and agree that all of my records, including x-rays, are permanent records of this Clinic. I authorize the release of any information relevant to my treatment, including information regarding treatment fees, to insurers and attorneys who are involved with my claim and their respective representatives. I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND IT.

THIS DOCUMENT IS MADE A PART OF THE ASSIGNMENT I HAVE SIGNED IN FAVOR OF THE CLINIC.

I HAVE RECEIVED A COPY OF THIS DOCUMENT.

______________________________________________ __________________________ Signature of Patient Date ______________________________________________ Print or Type Patient’s Name ______________________________________________ Signature of Parent or Legal Guardian ______________________________________________ Print or Type Name of Parent or Legal Guardian


ASSIGNMENT

I was involved in an accident on or around ______________________ [date] in which I was injured for which I have or may

have a claim against another person(s) for causing my injuries (including ____________________________) (referenced as

"My Claim"), who is insured by________________________.

In consideration of the agreement of Powell Chiropractic Clinic Inc. (referenced as the "Clinic") to delay billing me personally for medical treatment rendered until resolution of My Claim: 1. I now assign, without any right to later revoke a part of any proceeds from my claim equal to the fees incurred by me to

this Clinic for all treatment and other services rendered by this Clinic. I am not assigning any legal cause of action in My

Claim above, but only prospective proceeds. I also assign to the Clinic my right to enforce the obligation of any insurance

company to pay settlement proceeds for any settlement agreement made by or for me in exchange for my signing such

insurance company's release of claim. Prior to settlement or other disposition of My Claim, I understand and permit Clinic

to pursue payment from any other source but me personally, including medical payments coverage in an automobile

liability policy.

2. This Assignment and related documents which I have signed in connection with it states the entire agreement

and my complete understanding regarding the Clinic's fees. I have not relied on any statements by the Clinic or

the Doctor or other information before making this Assignment. I understand that I remain responsible for any

Clinic fees not paid out of My Claim.

_________________________________________ Signature of Patient

3. I understand that it is my responsibility during treatment to remain aware of my cumulative account balance for

services rendered. I have received a schedule of treatment fees for this Clinic, or if I have not, will request this

Clinic for one in writing.

4. I understand that this is an express contract to pay for the services rendered by this Clinic. I agree to pay my account

balance in full and/or direct its payment from My Claim proceeds regardless of whether any other person or entity

attempts to or fails to fully reimburse me for it. If I dispute my account balance or treatment rendered, I agree that my

remedy will be to resolve it with a separate action from My Claim.

5. NOTICE: I DIRECT ANY INSURANCE COMPANY, ATTORNEY, OR OTHER PERSON WHO HOLDS OR LATER

HOLDS ANY PROCEEDS FROM MY CLAIM TO APPLY ANY PROCEEDS FROM MY CLAIM TO MY TOTAL

ACCOUNT BALANCE OUT OF THE TOTAL PROCEEDS HELD IN MY BEHALF, UNLESS THE CLINIC CONFIRMS

PRIOR PAYMENT OF IT IN WRITING. "TOTAL PROCEEDS" HELD BY AN ATTORNEY FOR MY CLAIM SHALL

MEAN PROCEEDS AFTER DEDUCTION OF ATTORNEY FEES.

6. This Assignment is governed by Ohio law. Jurisdiction shall be in Ohio, and venue shall lie in the county in which the

Clinic is located, unless required by applicable law to lie in a different county in which I reside.

7. I REALIZE THAT I HAVE NOW GIVEN AWAY A PART OF ANY PROCEEDS FROM MY CLAIM. IF I RECEIVE ANY

PROCEEDS FROM MY CLAIM, I AGREE TO IMMEDIATELY DETERMINE IF THIS CLINIC HAS BEEN SEPARATELY

PAID IN FULL. UNLESS THE CLINIC CONFIRMS FULL PAYMENT IN WRITING, I REALIZE THAT ANY USE BY ME

OF THESE PROCEEDS IS TAKING OR CONVERTING MONEY THAT IS THE PROPERTY OF THIS CLINIC.

8. I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND IT.

_____________________________________________________ ___________________________________ Signature of Patient Date

_____________________________________________________ This Assignment Has Been Signed On The Print or Type Patient’s Name Clinic Premises:

_____________________________________________________ ___________________________________ Signature of Parent or Legal Guardian Staff Witness

Name of Person at Fault

Copyright 1999 John P. Lowry, Esq.

Boehm, Kurtz & Lowry, Attorneys at law


Office Financial Policy It is our office policy that all services rendered are the responsibility of the patient, and that you are ultimately personally responsible for all payments regardless of whether or not this office accepts insurance assignment.

1. Patients without insurance:

All payments are expected at the time of service, or preset a payment plan or program. Personal

balances should not exceed $150 at any time, unless on a pre-arranged payment plan.

2. Patients with insurance:

Deductibles and all co-payments are expected at the time of service, or preset on a payment plan.

Your patient responsibility balance should not exceed $150, unless on a pre-arranged payment

plan.

It is the policy of this office to extend to our patients the courtesy of assigning your insurance benefits directly to us. We are happy to extend this credit to you so that you can follow through with all of the care you may require. The following are important points of consideration to be aware of:

1. The privilege of insurance assignment begins when our office receives and verifies your insurance

information.

2. As a courtesy to you, our office will pre-qualify your insurance coverage, in an effort to help you

determine what coverage is available to you under your policy. We will help you make the best

estimate of your coverage for the recommended services. This service is a courtesy to you and not a

guarantee of payment.

3. As a courtesy, this office will submit secondary insurance, if necessary.

4. If your insurance has not paid on an assigned bill within 60 days, you will be notified. Since we do

not own your policy, we may ask you to stay in communication with our office and take action with

your insurance company at that time. If it remains unpaid within 90 days, the balance becomes due

and payable immediately, and your assignment is revoked.

5. If your insurance benefits reach a maximum, you agree that any additional care you receive at

Powell Chiropractic Clinic will be your financial responsibility.

6. All patients whose treatment visitation schedule is once per month or longer may not be eligible for

insurance assignment as this level of care is rarely covered by insurance. Our office offers wellness

plans to allow you to continue needed care.

7. No one can predict what an insurance company will pay for the usual and customary charges for

services rendered. If we participate on your plan, you will not encounter balance billing above the

stated fee schedule. If we do not participate, we will work with you to determine the amount of

coverage and help estimate your responsibility.

8. Should you discontinue care for any reason; any and all balances will become due and payable at

that time. If you are on a predetermined payment plan, that plan will continue to be in effect until

your balance in zero, unless you fail to keep up with your payment plan.

9. If the patient being treated is a minor, a parent/guardian must be present at the time of the initial

and report of findings appointment, which are the first and second appointments as a new patient.

This is so treatment and financial arrangements can be explained to the parent/guardian. For

services rendered to minor patients, the parent(s) or guardian(s) of the minor are responsible for

payment.

10. The goal of our office is to provide you with the finest quality chiropractic care available. If you have

any questions with regard to your health care or any of our policies, please let us know. Signed:___________________________________________________________ Date:_______________ Staff Initials:_______________


Billing Agreement Our billing department will make every effort to ensure your claims get paid as quickly and easy as possible. Due to the fact that there are a lot of changes with insurance policies and multiple types of plan coverages, we are forced to follow their guidelines. Unfortunately, how they apply deductibles, copayments, payments, and denials is up to them, not us. At that time, if we see something is incorrect, we will appeal only once. If it exceeds one appeal, we will contact you, and at that time you must get involved. Because insurance companies are continuously changing what they cover, how they cover, and what they make your responsibility, you, as the policy holder, are required to understand your insurance plan and be involved through the process. Remember, it is your insurance policy, not ours. We are the middle man, and cannot make decisions regarding what your insurance pays and what they do not. You will receive an Explanation of benefits (EOB) from your insurance company. Please review them. If there is ever a time you feel like something is incorrect with what your insurance company paid, or what you feel is your responsibility, YOU MUST contact your insurance company. One thing to keep in mind is that that each insurance policy has what is called a “Timely Filing.” That means, they only allow us as the provider, and you as the policy holder, a certain amount of time to appeal or work with a claim. That time can range anywhere from 6 months to 2 years depending on the insurance company and your policy. Once that time is up, you will become fully responsible for all of the charges at full price. You will receive monthly statements ONLY if you have a current balance. Please remember that it can take weeks to hear back from your insurance company, and sometimes statements and EOB’s can cross paths. When you make payments on your account, we apply that payment to the oldest date of service with an outstanding balance, to avoid sending those claims to collections. It WILL NOT affect your balance total if what you thought you paid for and what it was applied to do not match. We apologize for any inconvenience that this may cause, but appreciate your understanding and patience. Please know we only have the best interest of our patients and we will try our best to make this process as easy as possible. Thank you, Amanda Deeser Billing Department Amy Marceric Office Manager Print Name ____________________________________________________ Date _________________ Signature _____________________________________________________


Name: DOB: Date: What is your chief complaint? Neck pain Arm Pain ( Right Left ) Low Back Pain Leg Pain ( Right Left )

Other:

How long have you suffered with these symptoms?

How would you describe your pain? Aching Dull Numbing Sharp Shooting Throbbing Tingling

Please describe your symptoms:

Does it radiate or travel into another part of the body? Yes No If so, where:

Pain scale evaluation (Circle your pain level): No Pain 0 - 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10 Intense Pain

When is the pain worst (Circle your response): Morning Mid-day

Evening

Family history of similar conditions? Yes No

Any weakness in arms or legs? Yes No Arms Legs Right Left

Both

Poor circulation in arms or legs? Yes No Arms Legs Right Left

Both

Blurred vision or change in eye function? Yes No Right Left

Dizziness or balance issues? Yes No Dizziness Poor balance Both

Do you suffer from any of the following: Circle all that apply

Chronic sinus issues Low grade fever Unexplained Weight loss Night sweats Issues

with fatigue Bowel/bladder changes or loss of control Male/Female disorders

Other/Details: Previous Care: Date/Details Date/Details

Pain Management: Surgery:

Physical Therapy: Chiropractic:

Medication: Acupuncture:

Other:

Any treatment success?

Other information we should know:

Patient Signature:


Name: Date:

PLEASE FILL OUT ALL AREAS Chart Number:

Primary Care Physician:

Address:

City, State, Zip:

Phone Number:

Have you had blood work within the last year? ____________________________________________

Do we have your permission to request Records from the office? ____________________________

Patient Name: Date of Birth: Phone: Address: City: State: Zip: 1. I authorize the use or disclosure of the above named individual’s health information as described below. 2. The following individual or organization is authorized to make the disclosure:

Name: POWELL CHIROPRACTIC CLINIC, INC Address:4867 Munson ST NW City: Canton State: Ohio Zip: 44718 Phone Number: 330-494-5533 Fax Number: 330-494-8101 3. The type and amount of information to be used or disclosed is as follows: (include dates where appropriate).

Complete Health Records X Lab Results/X-ray Reports Physical Exam Consultation Reports Immunization Record

4. I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse.

5. This information may be disclosed to and used by the following individual or organization: 6. I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I

must do so in writing and present written revocation to the health information management department. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event, or condition: 12 months from signing date.

7. If I fail to specify an expiration date, event, or condition, this authorization will expire in 60 days. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized disclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact:

Privacy Officer for

Signature of patient or legal representative Signature of witness Date: Date:


(330) 494-5533 Fax: (330) 494-8101

4867 Munson Street NW · Canton, Ohio · 44718


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