Name
*
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Primary Phone
*
(###)
###
####
Secondary Phone
(###)
###
####
Email
Primary Insurance (Plan name and ID#)
Secondary Insurance (Plan name and ID#)
Since your last visit, have you experienced any of the following:
Please provide details and dates for any items checked above.
What symptoms are you experiencing? (Check all that apply)
*
When did this discomfort begin? Do you know the cause? Please describe any additional symptoms or concerns.
Have you had any new x-rays, MRIs, Bone density, or CT scans in the last two years?
Rate your discomfort level from 1 to 10 (10 being the worst)
Assignment/Authorization/Release
*
I certify that I, and/or my dependents, have insurance with the above named insurance company(s) and assign directly to Sean Marcella, DC, Jackson Highley, MA, DC, and/or Stephen Kongs, DC, all benefits, if any, otherwise payable to me for services rendered. I authorize the use of my signature on all insurance submissions. I understand that “co pays” are payable at the time of each visit and that I am financially responsible for all charges whether or not paid by insurance. The above named provider’s office may use my health care information and may disclose such information to the above named insurance company(s) and their agents for the purpose of obtaining payment for services and determining benefits payable for related services.
HIPAA Compliance
*
I acknowledge that a copy of the patient “Notice of Privacy Practices” is available to me upon request.
In addition to the allowable disclosures described in the “Notice of Privacy Practices”, I hereby specifically authorize Disclosure of my protected health care information to the Persons indicated below.
Responsible Party Electronic Signature
*
First Name
Last Name
Today's Date
*
MM
DD
YYYY
