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Bahnemann Family Chiropractic, PC: Registration and History
PAYMENT INFORMATION __ Auto Insurance Claim __Commercial Insurance __No Insurance (Self Pay) __Medicare __Worker’s Compensation If this is a Commercial Insurance Claim, please fill out the following “Assignment and Release” and provide your health insurance card to the receptionist so she can make a copy of the card. We will file the insurance claim for you. ASSIGNMENT AND RELEASE
I, the undersigned, certify that I (or my dependent) have insurance coverage with _______________________and assign directly to Bahnemann Family Chiropractic, PC all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
___________________________________________________ Responsible Party Signature ________________________________ _______________ Relationship Date
PATIENT INFORMATION
Date____________________
Patient_________________________________________
Patient Social Security ____________________________
Address________________________________________
_______________________________________________
City State Zip
Email__________________________________________
Would you like to receive correspondence via e-mail? Y/N
Sex: M F Age_____ Birth Date___________________
Single Married Widowed Separated Divorced
Occupation______________________________________
Employer_______________________________________
Spouse’s name__________________________________
Birthdate___________Occupation____________________
Whom may we thank for referring you?________________
_______________________________________________
PHONE NUMBERS
Home____________ Work_____________ Ext._____
Cell_______________ Best number to reach you
May we remind you of your next appointment via text msg or
e-mail? (Circle one) Yes/ No
If yes, specify info: ____________________________
IN CASE OF EMERGENCY, CONTACT
Name______________________Relationship_______
Phone____________________ Alt Ph_____________
ACCIDENT INFORMATION
Is condition due to an accident? __Y __N Date________
Type of accident __Auto __Work __Home __Other
To whom have you made a report of your accident?
__Auto Ins __Employer __Work Comp. __Other
Information for Auto Claims Only:
Name of Auto Insurance:__________________________
Claim #__________________Ph #__________________
Adjuster’s Name:________________________________
ACCIDENT DIAGRAM
NOTICE OF DOCTOR'S LIEN LIEN AGREEMENT
I do hereby authorize Dr. Kerri Bahnemann, DC to furnish you, __________________________ Insurance Company, which will be referred to as “my insurance company” throughout this document, with a full report of her examination, diagnosis, treatment, prognosis, etc., of myself in regard to the accident on _________, in which I was recently involved.
I hereby authorize and direct you, my insurance company to pay directly to said doctor such sums as may
be due and owing her for medical service rendered me both by reason of this accident and by reason of any
other bills that are due her office, and to withhold such sums from any settlement, judgment or verdict which
may be necessary to adequately protect said doctor. I hereby further give a first party lien on my case to Dr.
Kerri Bahnemann, DC against any and all proceeds of my settlement, judgment or verdict which I have been
treated of injuries in connection therewith.
I hereby direct any attorney to recognize and honor this lien and to pay you directly from the proceeds allocated to me in his attorney trust account at the time he receives them. I have personally served my attorney with a copy of this lien and as principal have put my attorney, as my agent, on notice regarding his responsibility in paying you.
I agree never to rescind this document and understand that a rescission will not be honored by my
insurance company. I hereby instruct that in the event another insurance company is substituted or added
in this matter, the new insurance, company honor this first party lien as inherent to the settlement and
enforceable upon the case as if it were initially executed by them.
I fully understand that l am directly and fully responsible to the said doctor for all medical bills submitted for
her for service rendered to me and that this first party lien agreement is made solely for the said doctor's
additional protection and in consideration of her awaiting payment. I further understand that such payment
is not contingent on any settlement, judgment or verdict by which I may eventually recover said fees.
Please acknowledge this letter by signing below and returning it to the doctor's office. I have been advised
that if my insurance company does not wish to cooperate in protecting the doctor's interest, the doctor will
not await payment but will require me to make payments on a regular basis to keep my account current.
DOA: ____________________ Patient’s Name _____________________________
Claim #: __________________ Patient’s Signature ___________________________
The understanding being a representative of the _____________________Insurance Company of record
for the above patient does hereby agree to observe all the terms of the first party lien and agrees to withhold
such sums from any settlement, judgment, or verdict, as may be necessary to adequately protect the said
doctor above named and to execute this lien in the first party on behalf of Dr. Kerri Bahnemann, DC.
___________________ _______________________________
Date: Insurance Company Representative Signature
Bahnemann, DC Family Chiropractic PC
7610 N Union Blvd #125Colorado Springs, CO 80920
Bahnemann Family Chiropractic, PC
CONSENT TO TREATMENT
Health care providers are required to advise patients of the nature of the treatment to be provided, the risks and
benefits of the treatment, and any alternatives to the treatment.
There are some risks that may be associated with treatment, in particular you should note:
a. 'While rare, some patients have experienced rib fractures or muscle and ligament sprains or
strains following treatment;
b. There have been rare reported cases of disc injuries following cervical and lumbar spinal adjustment
although no scientific study has ever demonstrated such injuries are caused, or may be caused, by spinal
or soft tissue manipulation or treatment.
c. There have been reported cases of injury to a vertebral artery following osseous spinal
manipulation. Vertebral artery injuries have been known to cause a stroke, sometimes with
serious neurological impairment, and may, on rare occasion, result in paralysis or death. The
possibility of such injuries resulting from cervical spine manipulation is extremely remote;
Osseous and soft tissue manipulation has been the subject of government reports and multi-disciplinary studies
conducted over many years and have demonstrated it to be highly effective treatment of spinal conditions
including general pain and loss of mobility, headaches and other related symptoms.
Musculoskeletal care contributes to your overall wellbeing. The risk of injuries or complications from
treatment is substantially lower than that associated with many medical or other treatments, medications,
and procedures given for the same symptoms.
I acknowledge I have discussed the following with my healthcare provider:
a. The condition that the treatment is to address;
b. The nature of the treatment;
c. The risks and benefits of that treatment; and
d. Any alternatives to that treatment.
I have had the opportunity to ask questions and receive answers regarding the treatment.
I consent to the treatments offered or recommended to me by my healthcare provider, including osseous and
soft tissue manipulation. I intend this consent to apply to all my present and future care with ___Kerri
Bahnemann, BS, DC (health care providers name).
Dated this day of 20_____
Patient signature (or Legal guardian) Signature of Witness
Print Name Print Name:
Patient Health lnformation Consent Form
We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we will begin any health care operations we must require you to read and sign this consent form stating that you understand and agree with how your records will be used. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent.
1. The patient understands and agrees to allow this chiropractic office to use their Patient Health Information (PHI) for the purpose of treatment, payment healthcare operations, and coordination of care. As an example, the patient agrees to allow this chiropractic office to submit requested PHI to the Health Insurance Company (or companies) provided to us by the patient for the purpose of payment. Be assured that this office will limit the release of all PHI to the minimum needed for what the insurance companies require for payment.
2. The patient has the right to examine and obtain a copy of his or her own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI. Our office is not obligated to agree to those restrictions.
3. A patient's written consent need only be obtained one time for all subsequent care given the patient in this office.
4. The patient may provide a written request to revoke consent at any time during care. This would not affect the use of those records for the care given prior to the written request to revoke consent but would apply to any care given after the request has been presented.
5. For your security and right to privacy, all staff has been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures in our office. We have taken all precautions that are known by this office to assure that your records are not readily available to those we do not need them.
6. Patients have the right to file a formal complaint with our privacy official about any possible violations of these policies and procedures.
7. If the patient refuses to sign this consent for the purpose of treatment, payment and health care operations, the chiropractic physician has the right to refuse to give care.
8. From time to time we may send you birthday cards or letters use your name on a birthday list or use your name on a referral board in our office. By your signature below you have given us permission to do so.
I have read and understand how my Patient Health Information will be used and I agree to these policies and procedures.
_________________________________________ __________________________ Patient Name Date
_________________________________________ Patient Signature
Bahnemann Family Chiropractic PC