Name Preferred Name Address City State Zip Home Phone Cell Phone Other Birthdate Age Gender (Check One) Female Male Prefer Not to Answer SSN# Email Occupation Employer

Status (Check One) Minor Single Married Divorced Separated Widowed Spouse/Partner’s Name Emergency Contact Name Relation Home Phone Cell Phone How Did You Hear About Our Office?

Reason for Visit

Is your condition a result of: Work Auto Accident Trauma Chronic Other

Briefly describe what happened When did this condition begin? Is it getting better or worse?
Have you had a similar condition in the past? Yes No
Have you seen any other doctors for this condition? Yes No
If Yes, whom?
Have you ever had chiropractic care before? Yes No
If Yes, whom?

Health History

Please list any surgeries/hospitalizations that you have had and the dates:
Please list serious past injuries and the dates:
Please list all serious medical condition/allergies that you have or ever had:
Please list all family members with major medical conditions:
Are you taking any of the following medications? Nerve Pills Pain Killers Muscle Relaxers Insulin Blood Thinners Tranquilizers Others
Do you take: Vitamins Supplements   Do you exercise? Yes No. If yes, how much?
Are you wearing: Heel Lifts Sole Lifts Orthotics Arch Support

Do you smoke? Yes No. If yes, how much? How long?
For women: Are you pregnant? Yes No.   Do you take birth control? Yes No.

When was your last cycle?

Do you currently have or ever had any of the follow diseases or conditions?

Other uses of medical information: We will ask for your written authorization before using or disclosing medical information about you in any other situation not covered by this notice. If you choose to authorize use or disclosure you can later revoke that authorization by notifying us in writing.

Your rights regarding personal medical information: In most cases you have the right to look at or get a copy of medical information that we use to make decisions about your care after submitting a written request. We may charge a fee for the cost of copying, mailing, or related supplies. If we deny your request to review or obtain a copy of your medical record, you may then submit a written request for a review of that decision.

If you think that information in your record is incomplete or incorrect you have the right to request that we correct the records by submitting a written request. We would deny the request when the information was not created by us, not part of the information maintained by us, or if the record was accurate. You may appeal in writing, a decision not to amend your record.

You have the right to a listing of those instances where we have disclosed medical information about you, other than for treatment, payment, or health care operations or where you specifically authorize the disclosure. You must submit a written request stating the time period desired for the accounting, which must be less than a six-month period. The first disclosure list in a 12-month period is free.

You have a right to a paper copy of this notice.

You have the right to request that medical information about you be communicated to you in a confidential manner, such as sending mail to an address other than your home, by notifying us in writing.

You may request in writing that we do not use or disclose your medical information for treatment, payment, or health care operations or to persons involved in your care except when specifically authorized by you, when required by law, or in an emergency.

We are not legally required to accept you request, but will consider it and inform you of our decision. All written requests or appeals should be submitted to Dr. James A. Devine.

Complaints:

If you are concerned that your privacy rights may have been violated, or you disagree with a decision we made about access to your records, you may contact Dr. James A. Devine at 104 pike St Suite 210, Seattle, WA 98101.

Finally, you may send a written complaint to the U.S Department of Human Services Office Civil Rights. We will happy to provide the address.

Under no circumstance will you be retaliated against of penalized in any way.

I hereby authorize the Doctor to treat my conditions as he or she deems appropriate. It is understood and agreed that the amount paid the Doctor, for x-rays, is for the examination only and the x-ray negatives will remain the property of this office, being on file where they may be seen at any time while a patient of this office. The patient also agrees that he/she is responsible for all bills incurred at this office.

Acknowledgement:

By signing my name below, I acknowledge receipt of a copy of this notice, and my understanding and agreement to its terms.

Printed Name
Signature     Date
Consent to Treat Minor     Date
Guardian Signature Authorizing Care     Date

Notice of Privacy Practice

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

The information privacy practices in this notice will be followed by:

Any health care professional that treats you in our office.

All departments and units including the Billing Department.

All full, part time, or contractual employees, including students affiliating with any of our clinics.

Any business associate or partner of Devine Chiropractic & Rehab Center, P.S. with whom we share health information.

Our pledge to you: We value you as a patient and appreciate the opportunity to serve you. We are committed to protecting medical information about you. We create a record of the care and services you receive to provide quality care and to comply with legal requirements. By law, we are required to:

Keep medical information about you private.

Give you this notice or our legal duties and privacy practices.

Follow the terms of the notice that is currently in effect.

Changes to this notice: We may change our policies at any time. Changes will apply to medical information we already hold and to the future information after the change occurs. Before we make significant change to our policies, we will alter our notice and post the new notice for public view in our office. You can receive a copy of the notice at any time. You will also be asked to acknowledge in writing your receipt of this notice.

How we may use and disclose your personal medical information: We may use and disclose medical information about you for any purpose regarding your treatment, to obtain payment for treatment (such as sending billing information to your insurance company or Medicare), and for health care operations (such as comparing practice patterns to improve treatment methods).

We may use and disclose medical information about you without your prior authorization for several other reasons, subject to certain requirements: for public health purposes, abuse or neglect reporting, health oversight audits or inspections, research studies, workers’ compensation purposes, and emergencies. We also disclose medical information when required by law (such as in response to valid judicial or administrative orders).

We also may contact you for appointments reminders, or to tell you about or recommend possible treatment options, alternatives, health related benefits, or durable medical goods that may be of interest to you.

We may disclose medical information about you to a friend or family member who is involved with your medical care.

Accepted by (Print Name):   Date
Signature:

Informed Consent

I understand that my doctor’s recommendations are paramount for my optimum health and the improvement of my condition. Failure to follow my doctor’s recommendations may hinder or prolong my recovery and increase the number of visits required to correct my problem.

I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures including, but not limited to, diagnostic x-rays on me (or the patient named below, for whom I am legally responsible) by any licensed doctor of chiropractic who treats me at Devine Chiropractic & Rehab, P.S.

I have had the opportunity to discuss with my doctor at Devine Chiropractic & Rehab Center, P.S. and/or other office personnel the nature and purpose of chiropractic adjustments and other procedures.

I understand an 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. I do not expect the doctor to be able to anticipate and explain all of the risks and complications of the procedure which the doctor feels at the time, based upon the facts then known, is in my best interest.

To Be Completed by Patient

Patient Name:
Signature:
Date Signed
Witness to Patient’s Signature:

If Patient is a Minor, Physically, or Legally Incapacitated to be completed by Patient’s Representative

Patient’s Name:
Name of Representative:
Date Signed
Signature of Representative:
Relationship of Authority of Patient’s Representative:

Name   Date
Date of Injury
Do you have Personal Injury Protection? Yes   No   I DON’T KNOW

Have you opened a claim with your insurance company? Yes   No

Auto Ins. Comp.
Policy #: Insurance Co. Phone #
Claims Ins. Co. Address
Claims Adjuster Claim #
Do you have an attorney? Yes   No

Please fill in information below if your answer is yes

Attorney’s Name Phone
Attorney’s Address
Other Driver’s Name
Ins. Comp. Phone
Policy # Claim #

All of the above information is correct to the best of my knowledge. I agree that Devine Chiropractic will bill my insurance company, however, I also agree that any balance owing is ultimately my responsibility.

Signature Date