Martin Chiropractic & Wellness, & Schrage Chiropractic Offices Of Dr .
Martin Chiropractic & Wellness, & Schrage Chiropractic Offices of Dr. Leslie Martin & Dr. Jennifer Howard (Schrage) 3675 N 129th Street Omaha, NE 68164 Patient Health History Legal Name First MI Last Address City State Cell Phone Zip Code Home Phone Email: (used for reminders/online scheduling) Patient Identification: *******************ALL INFORMATION REQUIRED************************ Date of Birth: / Marital Status (check one) Single - Patient SSN Gender (check one) Male Age / Married - Other Female Unspecified Spouse Name: (minimum last 4 digits) How did you hear about our office? Whom may we thank for your referral? (check one) Family Member* ICPA Website Friend* Physician* Internet Web Site Sign on Building Insurance Website Other* Other Chiropractor Support Group Phone Book Facebook Google Yahoo Bing YELP *Please Let us know whom to thank for your referral: Employment Status: (check one) Employed FT Student PT Student Other Retired Self Employed Employer Name: Phone: Insured Data Policy Holder: (check one if filing to insurance) Self Spouse Parent Other Employee Insured’s Name: Date of Birth / / Secondary Insurance Insured’s Name: Date of Birth / / Staff Use: Coverage Type Chiropractic Acupuncture Deductible Co-Pay Co-Insurance % Max Visits Emergency Contact Name: Phone: Relation (check one) Spouse Sibling Parent Friend Employee Appointment Reminders Reminders are automatically set up, if you wish to OPT out of Reminders reply STOP to the messages. MARTIN CHIROPRACTIC & WELLNESS, & SCHRAGE CHIROPRACTIC PC 10.2019
Do you currently USE Tobacco of any kind? Yes Former Tobacco Use Never Tobacco Use Have you had an X-ray or CT scan or MRI of your low back spine in the past Month? Yes No Have you ever seen a Chiropractor, M.D. or D.O. for Spinal Manipulation before? Yes No Have you ever had Acupuncture before? Yes No List current MEDICATIONS and or Over-the-counter Medications/Supplements If there are no current medications, check here: List any known MEDICATION or Food ALLERGIES: If no allergies are known, check here: To Be Performed by Clinic Staff: Height Date Weight Muscle Grip Right Staff Blood Pressure / Pulse O2 Left L R Bi Norm or Weakness: Mild Moderate Severe Orthopedic Evaluation/Range of Motion/Reflexes: MARTIN CHIROPRACTIC & WELLNESS, & SCHRAGE CHIROPRACTIC PC 10.2019
Reason for visit today (primary complaint): / When did your symptoms start? / Rate your intensity of pain for the region of complaint: (0 No Pain 5 Moderate 10 Unbearable) 0 1 2 3 4 5 6 7 8 9 10 What event or activity brought on your symptoms? How often do you experience your symptoms throughout the day? 0% 10% 20% 30% 40% 50% What describes the nature of your symptoms: Numbness Pinprick Throbbing Tightness Aching Radiating (Traveling) Tingling 60% Cramping Burning Sharp 70% 80% Catching Sharp with Movement Weakness 90% Cramping 100% Dull Stabbing Other What makes your condition worse: What makes your condition better: How has your symptoms changed since the onset? Get Better Same Get Worse Does your pain or symptoms wake you up at night? Yes No Does your pain travel or radiate from one part of your body to the other? Yes No By using the diagram below, please indicate on the body where you are experiencing your symptom Have you applied Ice to the affected area? Yes No Have you applied Heat to the affected area? Yes No Have you seen anyone else for this condition? Yes No *If Yes Whom: Additional Complaints or Information: MARTIN CHIROPRACTIC & WELLNESS, & SCHRAGE CHIROPRACTIC PC 10.2019
Personal & Family Health History: Please check corresponding boxes if YOU currently have or have had the condition in the past. Please also indicate if your FAMILY history is affected by any of these conditions as well. M Mother F Father S Sister B Brother C Child Cardiovascular: Present Past Family History Ears/Nose/Throat: Present Past Family History Musculoskeletal: Poor Circulation Dizziness Gout High Blood Pressure Hearing Loss Arthritis Aortic Aneurism Sinus Infection Joint Stiffness Heart Disease Nosebleed Muscle Weakness Heart Attack Sore Throat Osteoporosis Chest Pain Difficulty Swallowing Broken Bones High Cholesterol Bleeding Gums Joints Replaced Pace Maker Present Past Family History Present Past Family History Present Past Family History Present Past Family History Present Past Family History Back Surgery Present Past Family History Jaw Pain Eyes: Irregular Heartbeat Glaucoma Endocrine: Swelling of Legs Double Vision Thyroid Disease Other: Blurred Vision Diabetes Hair Loss Genitourinary: Present Past Family History Integumentary: Present Past Family History Menopausal Kidney Disease Skin Ulcers Lower Side Pain Skin Disease Menstrual Problems Burning Urination Eczema Frequent Urination Psoriasis Depression Blood in urine Rashes Anxiety Disorder Kidney Stone Other: Unusual Stress Psychiatric: Other: Allergic/Immunologic: Blood/Lymphatic: Present Past Family History Hepatitis Present Past Family History Hives Weight Loss/Gain Energy Level Problem Difficulty Sleeping Immune Disorder Blood Clots HIV/AIDS Cancer Allergy Shots Easy Bruising Cortisone Use Easy Bleeding Other: Neurologic: Stroke Fevers/Chills/Sweats Seizures Gastrointestinal: Respiratory: Constitutional Present Past Family History Gallbladder Problems Present Past Family History Head Injury Brain Aneurysm Asthma Bowel Problems Numbness Tuberculosis Constipation Severe Headaches Shortness of Breath Liver Problems Pinched Nerves Emphysema Ulcers Parkinson's Disease Cold/Flu Diarrhea Carpal Tunnel Cough/Wheezing Nausea/Vomiting Spinning/Balance TOBACCO USE Bloody Stools MARTIN CHIROPRACTIC & WELLNESS, & SCHRAGE CHIROPRACTIC PC 10.2019
Martin Chiropractic & Wellness, & Schrage Chiropractic 3675 N 129th Street Omaha, NE 68164 www.AbsoluteOmahaChiropractic.com www.mcwomaha.com INFORMED CONSENT TO CHIROPRACTIC ADJUSTMENTS AND CARE I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physiotherapy and diagnostic x-rays, on me (or on the patient named below, for whom I am legally responsible) by the doctor of chiropractic named above. I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment including, but not limited to, fractures, disc injuries, strokes, dislocations and sprains. It is not reasonable to expect the doctor to be able to anticipate and explain all risks and complications of a given procedure on any particular visit, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known, is in my best interests. Chiropractic treatment involves the science, philosophy and art of locating and correcting spinal misalignments and as such, is oriented toward improvement of spinal function relative to range of motion, muscular and neurological aspects. There has been no promise, implied or otherwise, of a cure for any symptom, disease or condition as a result of treatment in this clinic. I understand that the chiropractor will use her hands or a mechanical device upon my body to adjust a joint, which may cause an audible “pop” or “click.” INFORMED CONSENT TO ACUPUNCTURE TREATMENT AND CARE I hereby request and consent to the performance of acupuncture treatments and other complementary medicine procedures including various modes of physiotherapy on me (or on the patient named below, for whom I am legally responsible) by the above named licensed Chiropractor. I understand that methods or treatment may include, but are not limited to, acupuncture with needles, moxabustion, electrical stimulation of the acupuncture point, or manual stimulation of the acupuncture point. Acupuncture attempts to normalize physiological functions, to modify the perception of pain, and to treat certain diseases of dysfunctions of the body. I have been informed that acupuncture is a safe method of treatment, but occasionally there may be some bruising or tingling near the needling sites that last a few days. There have been very rare instances reported of fainting, infection and scarring. There have been extremely rare instances reported of spontaneous miscarriage and pneumothorax. I understand that as part of my healthcare, this Practice originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves as a basis for planning my care and treatment; a means of communication among other health professionals who may contribute to my care; a source of information for applying my diagnosis and treatment information to my bill; and a means by which a third-party payer can verify that services billed were actually provided. I have read, or have had read to me, the Informed Consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. INFORMED CONSENT TO THIRD PARTY PAYER I understand that as part of my healthcare, this Practice originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves as a basis for planning my care and treatment; a means of communication among other health professionals who may contribute to my care; a source of information for applying my diagnosis and treatment information to my bill; and a means by which a third-party payer can verify that services billed were actually provided. I have read, or have had read to me, the Informed Consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. Signature: Patient or Legal Representative (Attorney, Guardian, Parent) Date Signed MARTIN CHIROPRACTIC & WELLNESS, & SCHRAGE CHIROPRACTIC PC 10.2019
HIPAA Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY. Uses and Disclosures: We will use and disclose elements of your protected health information (PHI) in the following ways: Without your signed authorization: Treatment at any providers office including obtaining your records from other providers as needed, including imaging or xrays Payment Health care operations When release is required by law, including in judicial settings and to health oversight regulatory agencies and law enforcement. In emergency situations or to avert serious health/safety situations. To medical examiners, coroners or funeral directors to aid in identifying you or to help them in performing their duties. To organ, tissue and other donation organizations, upon or proximate to your death if you have no indication on hand about your donation preferences. Special cases To contact you about appointment reminders, treatment alternatives and other health related benefits and services. To the sponsor of your health plan. Other All other uses and disclosure by us will require us to obtain from you a written authorization in addition to any other permission you will provide us. Your rights: You have the following rights concerning your PHI: Restrictions: To request restricted access to all or part of your PHI. We are not required to grant your request. Confidential communications: To received correspondences of confidential information by alternate means or location. Access: To inspect or receive copies of your protected health information. Amendments: To request changes be made to your PHI. We are not required to grant your request. Accounting: To receive an accounting of the disclosure by us of your PHI in the six years prior to your request. This notice: To get updates or reissue of this notice, at your request. Complaints: To complain to us or the U.S. Dept. of Health & Human Services if you feel your privacy rights have been violated. The law forbids us from taking retaliatory action against you if you complain. Our Duties: We are required by law to maintain the privacy of your PHI. We must abide by the terms of this notice or any update of this notice. Martin & Schrage Chiropractic is in compliance with the HIPAA Omnibus Rule. Martin & Schrage Chiropractic will not disclose Private Health Information without authorized permission from a patient. Private Health Information would be used/disclosed with authorized permission for marketing purposes. If you do not give express permission, we will not use your information for marketing purposes. If a patient requests a digital copy of certain electronic Private Health Information or directs Dr. Martin or Dr. Howard in writing to transmit a copy to another person, Dr. Martin or Dr. Howard will produce the information in the format requested (if readily producible) within 30 days or negotiate an alternative format. Further, if a patient request that a copy of his or her Private Health Information be sent via unencrypted email, the Dr. Martin or Dr. Howard will be permitted to do so, providing that the patient is aware of the risks and prefers the unencrypted email. Please be aware that Dr. Martin or Dr. Howard has the means to send some Private Health Information via encrypted email. If a patient would prefer an encrypted email, please inform Dr. Martin or Dr. Howard or a Staff Member. As a patient, you have a right to restrict any disclosures made to health plans for payment or health care operations purposes if the Private Health Information pertains to an item or service for which you paid COMPLETELY out of pocket. Martin & Schrage Chiropractic has completed a Risk Assessment regarding Private Health Information and has found no breaches in security. If in the event a breach occurs Martin & Schrage Chiropractic will inform affected patients and perform another Risk Assessment to address any changes that need to be made. Martin & Schrage Chiropractic takes the protection of Private Health Information very seriously and maintains strict compliance with any and all HIPAA requirements. To read the HIPAA Omnibus Rule in its entirety and how it may pertain to you please visit: 3-01073.pdf By signing you are acknowledging that you have read the Update Privacy Policy. Signature: Patient or Legal Representative Date Signed MARTIN CHIROPRACTIC & WELLNESS, & SCHRAGE CHIROPRACTIC PC 10.2019
MARTIN CHIROPRACTIC & WELLNESS, & SCHRAGE CHIROPRACTIC PC 3675 N 129TH STREET OMAHA, NE 68164 402-614-8334 402-885-8783 Consent to use PHI Acknowledgement for Consent to Use and Disclosure of Protected Health Information Use and Disclosure of your Protected Health Information Your Protected Health Information will be used by Stafford Corp, dba Martin Chiropractic & Wellness, & Schrage Chiropractic PC or may be disclosed to others for the purposes of treatment, obtaining payment, or supporting the day-to-day health care operations of this office. Notice of Privacy Practices You should review the Notice of Privacy Practices for a more complete description of how your Protected Health Information may be used or disclosed. It describes your rights as they concern the limited use of health information, including your demographic information, collected from you and created or received by this office. Initial One I have RECEIVED a copy of the Notice of Patient Privacy Policy.(Initial here to receive a copy) Patient Initials I have DECLINED a copy of the Notice of Patient Privacy Policy. (Initial here if you do not want a copy) Patient Initials Requesting a Restriction on the Use or Disclosure of Your Information You may request a restriction on the use or disclosure of your Protected Health Information. This office may or may not agree to restrict the use or disclosure of your Protected Health Information. If we agree to your request, the restriction will be binding with this office. Use or disclosure of protected information in violation of an agreed upon restriction will be a violation of the federal privacy standards. Notice of Treatment in Open or Common Areas Therapy services may be provided in a common room with more than one patient receiving treatment at a time. Chiropractic care and acupuncture along with examinations are performed in private rooms. Revocation of Consent You may revoke this consent to the use and disclosure of your Protected Health Information. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected. By my signature below I give my permission to use and disclose my health information. Patient or Legally Authorized Individual Signature Date Print Patient’s Full Name Time Witness Signature Date MARTIN CHIROPRACTIC & WELLNESS, & SCHRAGE CHIROPRACTIC PC 10.2019
Financial Policy Insurance Coverage Welcome to Martin Chiropractic & Wellness Schrage Chiropractic. Your insurance policy is an agreement between you and your insurer, not between your insurer and this clinic. Like all types of care, coverage for chiropractic services varies from insurer to insurer and plan to plan. Most insurance policies require the beneficiary to pay co-insurance, co-payment and/or a deductible. For example: if you have a deductible of 100, and your insurance pays 80%, you are responsible for 20% of all charges incurred during the year after you have paid your 100 at the beginning of the year. Our clinic will call your insurer to verify your benefits; however, we are not responsible for your insurer’s final payment and benefit determinations. Payment Options In order to help you determine your responsibility toward payment for services, please read the following, and initial your preference for the method of payment of your account. Please notify this office if the status of your insurance changes. Choose ONE Option A-F CASH: A I want to pay with CASH or CREDIT for each treatment. As I have no insurance, I agree to assume all responsibility and to keep my account current by paying for services when they are rendered. B I have insurance, but I wish to file my claims personally, and I agree to assume all responsibility and to keep my account current by paying for each visit at the time services are rendered. Health Insurance: C I would like this clinic to bill my insurance. I understand I am responsible for the costs of treatment including deductible, co-pays or co-insurance. Personal Injury (Car accident/Work Related Accident – Third Party Pay): D I want to use my Med Pay – Insurance through my own auto insurance coverage. Med pay will pay your bill as you go, and be reimbursed from the at-fault insurance when you settle. If your med pay insurance is exhausted before your treatment is complete, then the at-fault insurance company will be billed. E I want to use my personal insurance. (If you are a Blue Cross Blue Shield participant you must choose this option as they require all claims be sent directly to them). F I want to pay with CASH or CREDIT for each treatment. I understand that I can turn the receipt of payment into my Med-Pay or At-Fault for reimbursement when I settle. I understand that all health services rendered to me and charged to me are my personal financial responsibility. I understand and agree to the conditions of this policy. Signature Date MARTIN CHIROPRACTIC & WELLNESS, & SCHRAGE CHIROPRACTIC PC 10.2019
MARTIN CHIROPRACTIC & WELLNESS, & SCHRAGE CHIROPRACTIC PC 10.2019 Martin Chiropractic & Wellness, & Schrage Chiropractic 3675 N 129th Street Omaha, NE 68164 www.AbsoluteOmahaChiropractic.com www.mcwomaha.com INFORMED CONSENT TO CHIROPRACTIC ADJUSTMENTS AND CARE I hereby request and consent to the performance of chiropractic adjustments and .
Martin & Schrage Chiropractic 10.2016 Martin & Schrage Chiropractic 3675 N 129th Street Omaha, NE 68164 www.AbsoluteOmahaChiropractic.com www.mcwomaha.com INFORMED CONSENT TO CHIROPRACTIC ADJUSTMENTS AND CARE I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of
Aug 28, 2020 · Pathways to Wellness Personal Wellness Plan 1 Pathways to Wellness Personal Wellness Plan Use this Personal Wellness Plan to create a path to wellness that’s right for you. Come back to these questions often as the semester goes
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Chiropractic Board, Ohio State The Ohio State Chiropractic Board licenses and regulates the practice of chiropractic authorized by the Chiropractic Practice Act, Chapter 4734. of the Revised Code, and issues certificates to practice acupuncture to qualified chiropractic physicians. Construction Industry Licensing Board, Ohio (Commerce)
Definitions ASH Plans: American Specialty Health Plans of California, Inc., a California corporation. Chiropractic Services: Services provided or prescribed by a chiropractor (including laboratory tests, X-rays, and chiropractic appliances) for the treatment of your Neuromusculoskeletal Disorder. Emergency Chiropractic Services: Covered Chiropractic Services provided for the treatment of a .
Definitions ASH Plans: American Specialty Health Plans of California, Inc., a California corporation. Chiropractic Services: Services provided or prescribed by a chiropractor (including laboratory tests, X-rays, and chiropractic appliances) for the treatment of your Neuromusculoskeletal Disorder. Emergency Chiropractic Services: Covered Chiropractic Services provided for the treatment of a .
Bulletin, Interstate Chiropractic Schools [BJ LD 2535.I563 B7] Carver Chiropractic Institute, 1923-1924 [BJ LD 801.C3661 A4 B9 1923-24] Columbia Institute of Chiropractic [BJ LD 1211 .C7 C65 1945; BJ LD 1211 .C7 C65 1947] Eastern Chiropractic Institute, Annual Catalogue [BJ LD 1741.E463 C38, 192-?]
Un additif alimentaire est défini comme ‘’ n’importe quelle substance habituellement non consommée comme un aliment en soi et non employée comme un ingrédient caractéristique de l’aliment, qu’il ait un une valeur nutritionnelle ou non, dont l’addition intentionnelle à l’aliment pour un but technologique dans la fabrication, le traitement, la préparation, l’emballage, le .
