2995 Baseline Rd, Suite 101 Boulder, Co 80303 P: 303‐829‐1040 F: 303‐440‐0905 · 2011. 2. 14. · 2995 Baseline Rd, Suite 101 Boulder, Co 80303 P: 303‐829‐1040 F: 303‐440‐0905

2995 Baseline Rd Suite 101 Boulder Co 80303 P 303‐829‐1040 F 303‐440‐0905

CONFIDENTIAL PATIENT INFORMATION How Did You Hear About Us 1113088 FriendsFamily What is their name _________________________________ 1113088 InternetWebsite 1113088Health Fair 1113088 Promotional CouponPamphlet 1113088 Other Health Care Provider 1113088 Phone Book 1113088 Other Resource___________________________________________________ Name ________________________________________________________ Sex 1113088M 1113088F Date _____________ Address __________________________________ City _______________ State___________________ Zip ___________________ H Phone (_____)__________________ W Phone (____)_______________ Date of Birth __________________ Age _________ email ________________ Occupation _________________________ Employer ________________

Marital Status 1113088Married 1113088Single 1113088Divorced 1113088Children Ages __________ Have you ever received Chiropractic Care 1113088Yes 1113088No If yes when _________________ Family Physician ________________________ Phone (_____) ______________ Medication(s) Reason for taking _________________________________ ________________________________ _________________________________ ________________________________ _________________________________ ________________________________ _________________________________ ________________________________ Type of Surgery Date ________________________________ __________________________________ ________________________________ __________________________________ ________________________________ __________________________________ In Case of emergency please notify ___________________ Phone (_____)________ IF YOU WERE INVOLVED IN AN ACCIDENT PLEASE COMPLETE THE FOLLOWING Did the injury occur at Work 1113088Yes 1113088No Date of Injury _____________ Time ______ Has the injury been reported to your supervisor1113088Yes No Name of supervisor ___________________ Is the injury the result of an Automobile Accident Yes No ldquoI do hereby certify that he preceding questions have been answered truthfully and completely to the best of my knowledge and beliefrdquo Would you like the option of paying bills online Yes No PatientGuardian Signature ____________________ Date_______________


PATIENT CONSENT CONSENT FOR TREATMENT I voluntarily consent to the rendering of care including treatment and performance of diagnostic procedures I understand that I am under the care and supervision of the attending physician and it is the responsibility of the staff to carry out the instructions of said physician CONSENT TO RELEASE OF INFORMATION By signing this form you are granting consent to High Altitude Spine amp Sport to use and disclose your protected health information for the purposes of treatment payment and health care operations This Privacy Policy provides more detailed information about how we may use and disclose this protected health information You have a legal right to review our Privacy Policy before you sign this consent and we encourage you to read it in full Our Privacy Policy is subject to change If we change our notice you may obtain a copy of the revised notice by contacting our office at (303) 829-1040 You have a right to request us to restrict how we use and disclose your protected health information for the purposes of treatment payment or health care operations We are not required by law to grant your request However if we do decide to grant your request we are bound by our agreement You have the right to revoke this consent in writing except to the extent we already have used or disclosed your protected health information in reliance on your consent

MEDICARE CONSENT TO RELEASE INFORMATION ldquoI certify that the information given me in applying for payment under Title XVIII of the Social Security Act is correct I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediary carriers any information needed for this or related Medicare claimrdquo Print Patientrsquos Name _____________________________________ Patientrsquos Signature ______________________________________ Date ____________________


NOTICE OF PRIVACY PRACTICES

Welcome to High Altitude Spine amp Sport Because your satisfaction is our first priority we strive to provide you with information concerning our office policies and procedures This privacy notice discloses our information gathering and dissemination practices The health care profession has been and continues to be bound by professional standards of confidentiality Therefore we will protect your right to privacy In the course of providing chiropractic services to our patients we receive nonpublic personal information from and about our patients by means of a case history As a patient of High Altitude Spine amp Sport you should know that all nonpublic personal information that we receive from current and former patients is held in confidence and is not released to people outside this office except as agreed to by you with your written authorization or as required or permitted by law for the purposes of treatment payment and health care operations We request that all nonaffiliated third parties keep all information absolutely confidential and to use it solely for the purpose for which it is disclosed You can be assured that we do not sell or loan information about our patients or provide patient lists to outside mass marketing organizations We retain records relating to professional services that we provide so that we are better able to assist you with your health needs and in some cases to comply with professional guidelines In order to guard your nonpublic personal information we maintain physical electronic and procedural safeguards that comply with our professional standards and federal standards You have the following rights with respect to your protected health information which you can exercise by presenting a written request to our office The right to request restrictions on certain uses and disclosures of protected health information including those related to disclosures to family members other relatives close personal friends or any other person identified by you We are however not required to agree to a requested restriction If we do agree to a restriction we must abide by it unless you agree in writing to remove it bull The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or alternative locations

o The right to inspect and copy your protected health information o The right to amend your protected health information

bull The right to receive an accounting of disclosures of protected health information bull The right to obtain a paper copy of this notice from us upon request Please do not hesitate to call us at (303) 829-1040 if you have any questions or require any additional information _________Patient Initials You may submit a formal complaint to the Department of Health and Human Services Office of Civil Rights Huber H Humphrey Bldg 200 Independence Ave SW Room 509F Washington DC 20201



Past Health History

Please circle any conditions you currently have and put an X next to any condition you have had previously

AIDSHIV Alcoholism Allergy Shots Anemia

Anorexia Appendicitis Arthritis Asthma

Bleeding Breast Lump Bronchitis Bulimia

Cancer Cataracts Chemical Dependent Chicken Pox

Diabetes Emphysema Epilepsy Fractures

Glaucoma Goiter Gonorrhea Gout

Heart Disease Hepatitis Hernia Herniated Disc

Herpes High Cholesterol Kidney Disease Liver Disease

Measles Headaches Miscarriage Mono

MS Mumps Osteoporosis Pacemaker

Parkinsonrsquos Pinched Nerve Pneumonia Polio

Prostate Problem Prothesis Psychiatric Care Rheumatoid Arth

Rheumatic Fever Scarlet Fever Stroke Suicide Attempt

Thyroid Problem Tonsillitis TB TumorGrowth

Typhoid Fever Ulcers Vaginal Infections Venereal Disease

Whooping Cough Colds Migraines Viral Infections

Vision Problems Fibromyalgia Flu Other___________________________________

Exercise Work Activity Habits

[ ] None [ ] Extreme Sports [ ] sitting ___ hrsday [ ] Smoking ___ packsday

[ ] Moderate [ ] Weightlifting [ ] standing ___hrsday [ ] Alcohol ___ drinksday

[ ] Daily [ ] other __________________ [ ] heavy labor ___hrsday [ ] Caffeine ___ cupsday

[ ] other ____________________ [ ] High Stress type ___________

Insurance Proceeds Assignment


By agreeing to this assignment of insurance benefits we will direct your insurance company to make payments for your chiropractic physiotherapy rehabilitation x‐rays diagnostic testing or any other reimbursable treatment or evaluations you receive to our clinic directly

In exchange for services and supplies rendered I do assign to High Altitude Spine and Sport PC any insurance proceeds including accident and health insurance benefits and bodily injury claim awards up to the amount of any unpaid balance on my account In giving this assignment I acknowledge that I will be responsible for the amount of any unpaid balance with interest as allowed by law

Signature ____________________________________________________________ Date ___________________________________

Records Release Authorization

You High Altitude Spine and Sport PC are authorized to release any information contained in my file to an insurance company attorney adjuster or member of my office staff including any contracted billing services representing the clinic in order to process any claim for reimbursement of charges incurred for supplies furnished to me or services rendered to me by you or another member of the clinic I further authorize phone contact with the above listed third parties should phone contact be required for the purpose of obtaining payment for charges outstanding

Signature _______________________________________________________________ Date _________________________________

Health Insurance Info

Carrier _______________________________________________________Ins Co Phone _________________________________

Address ________________________________________________________________________________________________________

Policy _____________________________________________________Group __________________________________________

Patient Relationship to the insured Self Spouse Child other___________________

If you are covered by another persons insurance please complete

Name of Insured__________________________________Phone of insured____________________DOB________________

Address of Insured____________________________________________________________________________________________

Insuredrsquos Employer_______________________________________________Employer Phone_________________________

Address of Employer_____________________________________________________________Plan ______________________

Auto Accident Ins Carrier________________________________________Contact Person_______________________

Address_________________________________________________________________________Phone________________________

Date of Accident__________________ Claim _____________________________________

Relationship to the Insured Self Spouse Child Other ________________________


PATIENT CONSENT CONSENT FOR TREATMENT I voluntarily consent to the rendering of care including treatment and performance of diagnostic procedures I understand that I am under the care and supervision of the attending physician and it is the responsibility of the staff to carry out the instructions of said physician CONSENT TO RELEASE OF INFORMATION By signing this form you are granting consent to High Altitude Spine amp Sport to use and disclose your protected health information for the purposes of treatment payment and health care operations This Privacy Policy provides more detailed information about how we may use and disclose this protected health information You have a legal right to review our Privacy Policy before you sign this consent and we encourage you to read it in full Our Privacy Policy is subject to change If we change our notice you may obtain a copy of the revised notice by contacting our office at (303) 829-1040 You have a right to request us to restrict how we use and disclose your protected health information for the purposes of treatment payment or health care operations We are not required by law to grant your request However if we do decide to grant your request we are bound by our agreement You have the right to revoke this consent in writing except to the extent we already have used or disclosed your protected health information in reliance on your consent

MEDICARE CONSENT TO RELEASE INFORMATION ldquoI certify that the information given me in applying for payment under Title XVIII of the Social Security Act is correct I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediary carriers any information needed for this or related Medicare claimrdquo Print Patientrsquos Name _____________________________________ Patientrsquos Signature ______________________________________ Date ____________________








Past Health History




























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Address ________________________________________________________________________________________________________

Policy _____________________________________________________Group __________________________________________








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Past Health History




























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Past Health History




























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Documents

2995 Baseline Rd, Suite 101 Boulder, Co 80303 P: 303‐829‐1040 F: 303‐440‐0905 · 2011. 2. 14. · 2995 Baseline Rd, Suite 101 Boulder, Co 80303 P: 303‐829‐1040 F: 303‐440‐0905