Welcome

Patient Information Insurance

Date _______________________________________________________________

Guardian Name ______________________________________________________

First Name___________________________________________________________

Last Name___________________________________________________________

Address _____________________________________________________________

City _______________________________________________________________

State_________________________________Zip ___________________________

Sex ❑ M ❑ F DOB:__________________ Age_______________

Social Security #______________________________________________________

❑ Married ❑ Widowed ❑ Single ❑ Minor

❑ Separated ❑ Divorced ❑ Partnered for ______years

Occupation __________________________________________________________

Patient Employer/School _______________________________________________

Home Phone (_______) ________________________________________________

Work Phone (_______)_________________________________________________

Cell Phone (_______)__________________________________________________

E-mail ______________________________________________________________

IN CASE OF EMERGENCY, CONTACT

Name __________________________________Phone_______________________

Spouse’s Name _______________________________________________________

Spouse’s Employer____________________________________________________

How did you hear about our office? _______________________________________

We are committed to providing you the best care and are pleased to discuss our

professional fees with you at any time. Your clear understanding of our financial

policy is important. Please ask any questions you may have regarding our fees or your responsibility in complying with our financial policy and/or procedures.

Cash Patients: Payments is due when services are rendered. We gladly accept major

credit cards, check or cash.

Insurance Patients: Please pay $120.00 for your first visit charges for Chiropractic

Care, or $95.00 for first Acupuncture Treatment. This will be credited to your account for any further charges. Professional services are rendered and charged to your

insurance on your behalf. Any services not covered by your insurance company are

ultimately your responsibility and may have to be paid by you at the time of service. If you fail to keep your scheduled appointments or if you discontinue care for any

reason other than discharged by the doctor, the bill is due and payable by you in full,

immediately, regardless of any insurance claim submitted. Our office accepts billing

for Individual or Group Insurance policies, Personal Injury claims, authorized

Worker’s Compensation and Medicare.

There is a $50 charge for No call, No show appointments without a 24 hour notice.

FINANCIAL RESPONSIBILITY I understand that insurance billing is a service provided as a courtesy and that I am at

all times financially responsible to Redondo Beach Chiropractic & Pain Relief Center

and/or its affiliated entities for any charges not covered by health care benefits. It is my responsibility to notify Redondo Beach Chiropractic & Pain Relief Center of any

changes in my health care coverage. In some cases exact insurance benefits can not be

determined until the insurance company receives the claim. I am responsible for the entire bill or balance of the bill as determined by Redondo Beach Chiropractic & Pain

Relief Center and/or my health care insurer if the submitted claims or any part of them

are denied for payment. I understand that by signing this form that I am accepting financial responsibility as explained above for all payment for medical services and/or

supplies received.

ASSIGNMENT OF BENEFITS

I authorize direct remittance of payment of all insurance benefits, including Medicare,

if I am a Medicare beneficiary, to Redondo Beach Chiropractic & Pain Relief Center for all covered medical services and supplies provided to me during all courses of

treatment and care provided by Redondo Beach Chiropractic & Pain Relief Center and/or its affiliated entities or otherwise at its direction. I understand and agree this

Assignment of Benefits will have continuing effect for so long as I am being treated

or cared for by Redondo Beach Chiropractic & Pain Relief Center, and will constitute a continuing authorization, maintained on file with Redondo Beach Chiropractic &

Pain Relief Center, which will authorize and allow for direct payment to Redondo Beach Chiropractic & Pain Relief Center of all applicable and eligible insurance

benefits for all subsequent and continuing treatment, services, supplies and/or care

provided to me by Redondo Beach Chiropractic & Pain Relief Center. Redondo Beach Chiropractic & Pain Relief Center may use my health care information and

may disclose such information to the above-named insurance Company(ies) and their agents, government agency, adjustor or attorney for the purpose of obtaining payment

for services and determining insurance benefits or the benefits payable for related

services. This consent will end when my current treatment plan is completed or one year from the date signed below.

_____________________________________________________________________

Signature of Patient, Parent, Guardian or Personal Representative

_____________________________________________________________________ Please print name of Patient, Parent, Guardian or Personal Representative

_____________________________________________________________________ Date

_____________________________________________________________________

Relationship to Patient

Accident Information

Is condition due to an accident? ❑ Yes ❑ No

Date of Accident______________________________________________________

Type of accident: ❑ Auto ❑ Work ❑ Home ❑ Other

To whom have you made a report of your accident?

❑ Auto Insurance ❑ Employer ❑ Worker Comp. ❑ Other

Attorney Name (if applicable) __________________________________________

Attorney Phone_______________________________________________________

Please describe the reason for your visit today (Chief Complaint):

Are you, or have you been, treated for this problem with any other health professionals?

What was your diagnosis? ________________________________________________________________________

Are you taking any Medication or Herbal Supplements? If so, which ones? (Add dosage if known):

Are you in generally good health, r do you frequently fall ill? _____________________________________________

What Illnesses might you be prone to? (ie, frequent colds, gastro-intestinal problems) _________________________

PERSONAL MEDICAL & FAMILY HISTORY

1) Please Circle any of your Current Health Issues

2) For condition that you have experienced in your past please indicate the year of occurrence.

3) Please Mark “F” to indicate if any family members suffer from a condition listed below.

Alcoholism

Allergies

Anemia

Appendicitis

Arteriosclerosis

Asthma

Bleeding disorder

Blood Pressure (low/high)

Cancer

Chicken pox

Diabetes

Digestive Disorders

Emotional Difficulties

Emphysema

Epilepsy

Fatigue

Gout

Heart Disease

Hepatitis (A, B, C)

High Blood Pressure

Hypoglycemia

Injuries

Insomnia

Intestinal Parasites

Multiple Sclerosis

Mumps

Pacemaker

Weight Loss or Gain

Polio

Scarlet Fever

Seizures

Stroke

Surgery (List):

Thyroid Disorder

Trauma (falls, accidents)

Tuberculosis

Ulcers

Other: -________________________

Which of the following are part of your lifestyle? How frequently do you engage in it?

Alcohol Nicotine Exercise Coffee Recreational Drugs Excessive Sugar

Do you usually eat 3 meals a day? __________ Do you follow any particular diet? _____________________________________________

On the scale of 1-10, how would you rate the level of stress in your life currently? __________________

What is the level of stress in your life in general (1-10)? _________________________

How does stress affect you? (ie, more headaches, stomach pain etc) __________________________________________________________

Are there any other concerns you would like to address? ___________________________________________________________________

REVIEW OF SYSTEMS

Please fill this out carefully, even if some of the symptoms don’t seem at all connected to your current issue!

Place one check next to a symptom you have experienced,

Place Two Checks next to a frequently occurring symptom,

Place Three Checks next to a symptom that is particularly distressing to you.

Head and Face Gastrointestinal Sleep

Headache Always Thirsty Insomnia

Dizziness Never Thirsty Drowsiness

Memory Loss Excessive Appetite Excessive Dreaming

Other_____________ Low Appetite Waking Easily

Gas/Bloating Other_______________

Eyes Stomach Pain

Blurry Vision Nausea Throat

Eyelid Twitching Diarrhea/Loose Stools Sore Throat

Floaters Constipation Hoarseness

Pain Rectal Bleeding Difficulty Swallowing

Colon Problems Dryness

Nose

. Frequent Colds Skin Urination

Sinus Trouble Acne Frequent

Bleeding Dryness Difficult

Moles that Change Painful

Mouth Lumps Nocturnal

Dental Problems Excessive Sweating Bleeding

Gum Problems

Night Sweats

Teeth Grinding/TMJ Rarely Sweat Respiration

Unusual Tastes Other _________________ Difficulty Inhaling

Other______________ Difficulty Exhaling

Neurological Pain

Heart and Chest Nervousness/Anxiety Cough

High Blood Pressure Tremors Congestion

Low Blood Pressure Numbness or Tingling Shortness of Breath

Chest Pain Lack of Coordination Other________________

Chest Tightness Nerve Pain

Difficulty lying down Other_________________

. Other______________

Circulation

. Easy Bruising

Cold Hands/Feet

Reynaud’s Syndrome

WOMEN ONLY

Are you, or could you be Pregnant? __________________

If so, how far along? ____________

Number of Pregnancies ___________ Births __________ Abortions__________ Miscarriages_________

Age of first menses________________ Age of Meopause, if applicable______________

Do you bleed between Periods? ___________

Have you ever had any gynecological surgeries or any abnormal findings on any tests?

_____________________________________________________________________________________

Are your periods uncomfortable orpainful, either emotionally or physically? __________

Are your periods:

Short (less than 28days)_____ long (28+days)_____ Varied_____ Regular_____

Painful? If so Before_____ During_____ After_____

Do you bleed heavily? _____ Lightly?_____ Very Little?_____

Do you have clots?_____ Early in the cycle_____ or throughout_____

Relative to the blood that comes from a wound, is your menstrual blood:

The same color_____ More pale_____ Purple_____ More Red_____ More Brown_____

How many days do you bleed? _____

Do you have any of the follwong Pre-Menstrual symptoms? (emotions are not judged in Chinese Medicine, they are neither good nor bad. They are, however, important diagnostic toos. Please answer honestly)

Irritable_____ Depression_____ Crying_____ Rage______ Nausea_____ Insomnia_____

Gas, Bloating_____ Cravings, and if so for what?_____________________

Any other symptoms around the time of your period?_________________________________________

Any other gynecological complaints listed here: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Redondo Beach Chiropractic & Pain Relief Center 700 N. Pacific Coast Highway #302 – Redondo Beach, Ca 90277

Notice of Privacy Practices Dear Patients: We do not ever want you to delay treatment because you are afraid your personal health history

might be unnecessarily made available to others outside of our office. We have put in writing the policies and

procedures we use to ensure the protection of your health information everywhere it is used i.e. internet, phone,

faxes, copy machines, and charts.

We will use and communicate your HEALTH INFORMATION only for the purposes of providing your treatment,

obtaining payment and conducting health care operations. Your health information will not be used for other

purposes unless we have asked for and been voluntarily given your written permission.

How your HEALTH INFORMATION may be used to provide treatment

We will use your HEALTH INFORMATION within our office to provide you with the best health care possible.

This may include administrative and clinical office procedures designed to optimize scheduling and coordination of

care between chiropractic assistant, chiropractor, office manager, and the billing staff. In addition we may share

your health information with referring physicians, clinical laboratories or other health care personnel providing you

treatment.

To Obtain Payment

We may include your health information with an invoice used to collect payment for future treatment you receive in

our office. We may do this with insurance forms filed for you in the mail or sent electronically. We will be sure to

only work with companies with similar commitment to the security of your health information. We have updated

our electronic billing software to be HIPAA compliant.

To Conduct Health Care Operations

Health information may be included in training programs for interns, associates, and business and clinical

employees. It is also possible that health information will be disclosed during audits by insurance companies or

government appointed agencies as part of their quality assurance and compliance reviews. Your health information

may be reviewed during the routine processes of certification, licensing or credentialing activities.

In Patient Reminders

Because we believe regular care is very important to your general health, we will remind you of a scheduled

appointment or that it is time for you to contact us and make an appointment. Additionally, we may contact you to

follow up on your care and inform you of treatment options or services that may be of interest to you or your

family. They may include postcards, folding postcards, letters, telephone reminders or electronic reminders such as

e-mail (unless you tell us that you do not want to receive these reminders).

Abuse or Neglect

We will notify government authorities if we believe a patient is the victim of abuse, neglect or domestic violence.

We will make this disclosure only when we are compelled by our ethical judgment, when we believe we are

specifically required or authorized by law or with the patient’s agreement.

Public Health and National Security

We may be required to disclose to Federal officials or military authorities health information necessary to complete

an investigation related to public health or national security. Health information could be important when the

government believes that the public safety could benefit when the information could lead to the control or

prevention of an epidemic.

For Law Enforcement

As permitted or required by State or Federal law, we may disclose your health information to a law enforcement

official for certain law enforcement purpose, including under certain limited circumstances, if you are a victim of a

crime or in order to report a crime

Redondo Beach Chiropractic & Pain Relief Center 700 N. Pacific Coast Highway #302 – Redondo Beach, Ca 90277

Family, Friends, and Caregivers

We may share your health information with family; however we will be sure to ask your permission first. In the

case of an emergency, where you are unable to tell us what you want we will use our very best judgment when

sharing your health information only when it will be important to those participating in providing your care.

Authorization to Use of Disclose Health Information

Other than what is stated above or where Federal, State or Local law requires us, we will not disclose your health

information other than with your written authorization. You may revoke that authorization in writing at any time.

Patient Rights:

• You have the right to request restriction on certain uses and disclosures of your health information. Our

office will make every effort to honor reasonable restriction preferences from our patients.

• You have the right to request that we communicate with you in a certain way. You may request that we

only communicate your health information privately with no other family members present or through

mailed communications that are sealed. We will make every effort to honor your reasonable requests for

confidential communications.

• You have the right to read, review and copy your health information, including your complete chart, x- rays

and billing records. If you would like a copy of your health information, please let us know. We may need

to charge you a reasonable fee to duplicate and assemble your copy.

• You have the right to ask us to update or modify your records if you believe your health information

records are incorrect or incomplete. We will be happy to accommodate you as long as our office maintains

this information. In order to standardize our process, please provide us with your request in writing and

describe your reason for change. Your request may be denied if the health information record in question

was not created by our office, is not part of our records or if the records containing your health information

are determined to be accurate and complete.

• You have the right to ask us for a description of how and where your health information was used by our

office for any reason other than for treatment, payment or health operations. Our documentations

procedures will enable us to provide information on health information usage form April 14, 2003 and

forward. Please let us know in writing the time period for which you are interested. Thank you for limiting

your request to no more than six years at a time. We may charge you a reasonable fee for your request.

• You have the right to obtain a copy of this Notice of Privacy Practices directly from our office at any time.

• You have the right to express complaints to us or to the Secretary of Health and Human Services if you

believe your privacy rights have been compromised. We encourage you to express any concerns you may

have regarding the privacy of your information. Please let us know of your concerns or complaints in

writing.

We are required by law to maintain the privacy or your health information and to provide to you and your

representative this Notice of Privacy Practices. We are required to practice the policies and procedures described in

this notice but we do reserve the right to change the terms of our Notice. If we change our Privacy Practices we will

be sure all of our patients receive a copy of the revised Notice

Patient Acknowledgment

Thank you very much for taking time to review how we are carefully using your health information. If you have

any questions we want to hear from you. If not we would appreciate very much you acknowledging your receipt of

our policy by signing, dating, and returning this Notice.

Patient Signature:_______________________________________________________Date:___________________

AAC-CA A2007

PATIENT NAME:

ARBITRATION AGREEMENT Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, including whether any medical services

rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California and federal law, and not by a lawsuit or resort to court process except as state and federal law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. Further, the parties will not have the right to participate as a member of any class of claimants, and there shall be no authority for any dispute to be decided on a class action basis. An arbitration can only decide a dispute between the parties and may not consolidate or join the claims of other persons who have similar claims.

Article 2: All Claims Must be Arbitrated: It is also understood that any dispute that does not relate to medical malpractice, including

disputes as to whether or not a dispute is subject to arbitration, as to whether this agreement is unconscionable, and any procedural disputes, will also be determined by submission to binding arbitration. It is the intention of the parties that this agreement bind all parties as to all claims, including claims arising out of or relating to treatment or services provided by the health care provider including any heirs or past, present or future spouse(s) of the patient in relation to all claims, including loss of consortium. This agreement is also intended to bind any children of the patient whether born or unborn at the time of the occurrence giving rise to any claim. This agreement is intended to bind the patient and the health care provider and/or other licensed health care providers, preceptors, or interns who now or in the future treat the patient while employed by, working or associated with or serving as a back-up for the health care provider, including those working at the health care provider’s clinic or office or any other clinic or office whether signatories to this form or not.

All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the health care provider, and/or the health care provider’s associates, association, corporation, partnership, employees, agents and estate, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress, injunctive relief, or punitive damages. This agreement is intended to create an open book account unless and until revoked.

Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall

select an arbitrator (party arbitrator) within thirty days, and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days thereafter. The neutral arbitrator shall then be the sole arbitrator and shall decide the arbitration. Each party to the arbitration shall pay such party’s pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees, witness fees, or other expenses incurred by a party for such party’s own benefit. Either party shall have the absolute right to bifurcate the issues of liability and damage upon written request to the neutral arbitrator.

The parties consent to the intervention and joinder in this arbitration of any person or entity that would otherwise be a proper additional party in a court action, and upon such intervention and joinder, any existing court action against such additional person or entity shall be stayed pending arbitration. The parties agree that provisions of the California Medical Injury Compensation Reform Act shall apply to disputes within this arbitration agreement, including, but not limited to, sections establishing the right to introduce evidence of any amount payable as a benefit to the patient as allowed by law (Civil Code 3333.1), the limitation on recovery for non-economic losses (Civil Code 3333.2), and the right to have a judgment for future damages conformed to periodic payments (CCP 667.7). The parties further agree that the Commercial Arbitration Rules of the American Arbitration Association shall govern any arbitration conducted pursuant to this Arbitration Agreement.

Article 4: General Provision: All claims based upon the same incident, transaction, or related circumstances shall be arbitrated in one

proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable legal statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence.

Article 5: Revocation: This agreement may be revoked by written notice delivered to the health care provider within 30 days of signature

and, if not revoked, will govern all professional services received by the patient and all other disputes between the parties.

Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (for example,

emergency treatment), patient should initial here. _______. Effective as of the date of first professional services.

If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy.

NOTICE: BY SIGNING THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.

(Date) PATIENT SIGNATURE X

(Or Patient Representative) (Indicate relationship if signing for patient)

(Date) OFFICE SIGNATURE X

.

ALSO SIGN THE INFORMED CONSENT ON REVERSE SIDE

AAC-CA A2007

ACUPUNCTURE INFORMED CONSENT TO TREAT

I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by the acupuncturist indicated below and/or other licensed acupuncturists who now or in the future treat me while employed by, working or associated with or serving as back-up for the acupuncturist named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping, electrical stimulation, Tui-Na (Chinese massage), Chinese herbal medicine, and nutritional counseling. I understand that the herbs may need to be prepared and the teas consumed according to the instructions provided orally and in writing. The herbs may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption of the herbs. I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Burns and/or scarring are a potential risk of moxibustion and cupping, or when treatment involves the use of heat lamps. Bruising is a common side effect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the clinic uses sterile disposable needles and maintains a clean and safe environment. I understand that while this document describes the major risks of treatment, other side effects and risks may occur. The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been recommended are traditionally considered safe in the practice of Chinese Medicine, although some may be toxic in large doses. I understand that some herbs may be inappropriate during pregnancy. Some possible side effects of taking herbs are nausea, gas, stomachache, vomiting, headache, diarrhea, rashes, hives, and tingling of the tongue. I will notify a clinical staff member who is caring for me if I am or become pregnant. While I do not expect the clinical staff to be able to anticipate and explain all possible risks and complications of treatment, I wish to rely on the clinical staff to exercise judgment during the course of treatment which the clinical staff thinks at the time, based upon the facts then known, is in my best interest. I understand that results are not guaranteed. I understand the clinical and administrative staff may review my patient records and lab reports, but all my records will be kept confidential and will not be released without my written consent. By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. 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.

ACUPUNCTURIST NAME:

(Date) PATIENT SIGNATURE X

(Or Patient Representative) (Indicate relationship if signing for patient)

ALSO SIGN THE ARBITRATION AGREEMENT ON REVERSE SIDE Bring this signed form with you for your initial office visit!