4640 Hypoluxo Rd., Ste.2, Lake Worth, FL 33463 (561) 296-1715 fax: (561) 296-1716 www.AHCPB.com

    NEW PATIENT INFORMATION


    Did you consult with any healthcare provider within the first 14 days after the accident, if so who

    ACCIDENT QUESTIONNAIRE

    Check All That Applies

    CompleteExtensiveMinimalModerate

    City RoadNeighborhood RoadOn/ Off RampHighway IntersectionMaking RT TurnMaking LT Turn

    Head-onHit on Left FrontHit on Right FrontHit on Left RearRear-EndedHit on Right RearOther

    Leaning ForwardLooking StraightTurned LeftTurned Right

    Go HomeGo About Your BusinessHospital by AmbulanceDriven to HospitalDrove Self to Hospital

    X-raysMRICAT ScanStitches

    INJURIES & SYMPTOMS

    Knocked out or unconsciousHeadachesFace painDizzinessRoom spinsBalance problemsDifficulty walkingVisual DisturbancesSleep DifficultyVery tired or fatiguedNausea / VomitingFlashbacks to accidentMemory problemsConfusionDifficulty speakingProblems to read or writeHearing problemsChange in sense of smell or taste

    Jaw painJaw clickingPain while chewingPain while talking

    Neck painNeck pain that causes headachesNeck pain that travels into RIGHT Shoulder Arm Hand Upper BackNeck pain that travels into LEFT Shoulder Arm Hand Upper Back

    Shoulder pain LEFTShoulder pain RIGHTShoulder pain BOTH

    Upper arm pain LEFT RIGHT BOTHElbow pain LEFT RIGHT BOTHForearm pain LEFT RIGHT BOTHWrist pain LEFT RIGHT BOTHHand pain LEFT RIGHT BOTH

    Upper back painUpper back pain into the neckMid-back painMid-back pain into the RIGHT rib cageMid-back pain into the LEFT rib cage

    Lower back pain LEFT RIGHT BOTHLower back pain that travels into RIGHT hip buttock thigh knee leg foot toeLower back pain that travels into LEFT hip buttock thigh knee leg foot toes

    Hip pain LEFT RIGHT BOTHHip pain that travels into RIGHT buttock thigh knee leg foot toesHip pain that travels into LEFT buttock thigh knee leg foot toes

    Leg pain LEFT RIGHT BOTHThigh pain LEFT RIGHT BOTHAnkle pain LEFT RIGHT BOTHKnee pain LEFT RIGHT BOTHFoot pain LEFT RIGHT BOTH

    Chest pain

    Stomach pain

    Health Histroy

    CHECK ANY OF THE FOLLOWING PAST MEDICAL PROBLEMS YOU HAVE HAD:

    Now

    Past

    Now

    Past

    Now

    Past

    Diabetes

    Thyroid Disease

    Osteoporosis

    Ulcers

    Goiter

    Polio

    Gastric Reflux/ GERO

    Kidney Disease

    Fractures

    Colitis/ IBD

    Pneumonia

    Multiple Sclerosis

    Hea11 Disease

    Tuberculosis

    Parkinson's

    Cone.estive Heart Disease

    Influenza

    Prostate Problems

    Blood Clots (DVT)

    Asthma

    Immune Disorder

    Peripheral Vascular Disease

    Emphysema

    Migraine Headaches

    Stroke

    COPD

    Seizure Disorder

    Pacemaker

    Bronchitis

    AIDS/HIV

    High Cholesterol

    Liver Disease

    Chemical Dependency

    High Blood Pressure

    Osteoarthritis

    Mental Disorders

    Bleedin Disorder

    Rheumatoid Arthritis

    Depression

    Anemia

    Gout

    Alcoholism

    CHECK ANY OF THE FOLLOWING PAST MEDICAL PROBLEMS YOU HAVE HAD:

    GENERAL

    EYES

    HEMATOLOGIC/ LYMPH

    SKIN

    ENDOCRINE

    MUSCULO-SKELETAL

    GASTROINTESTINAL

    CARDIOVASCULAR

    EAR/NOSF/THROAT

    GENITOURINARY

    NERVOUS SYSTEM

    RESPIRATION

    PSYCHIATRIC

    FEMALES ONLY

    cups/day

    packs/day

    CONSENT TO CARE

    You are the decision maker for your health care. Part of our role is to provide you with inf01mation to assist you in making informed choices. This process is often referred to as "infonned consent" and involves your understanding and agreement regarding the care we recommend, the benefits and risks associated with the care, alternatives, and the potential effect on your health if you choose not to receive the care. It is important that you understand, as with all health care approaches, results are not guaranteed, and there is no promise to cure.

    A patient coming to the doctor gives him/ her permission and authority to care for them in accordance with appropriate test, diagnosis, and analysis. We may conduct some diagnostic or examination procedures and clinical procedures if indicated, which rarely may cause some discomfort. These are usually beneficial and seldom cause any problem. In rare cases underlying physical defects, defonnities or pathologies, may render the patient susceptible for injury. The doctor or healthcare provider, of course, will not provide specific healthcare, if he/ she is aware that such care may be contraindicated. It is the responsibility of the patient to make it known or to learn through health care procedures from whatever he/ she is suffermg from: latent pathological defects, illnesses, or deformities, which would otherwise not come to the attention of the physician.

    Physical therapy is to treat disease, injury and disability by examination, evaluation, diagnosis, prognosis and intervention by use of rehabilitative procedures, mobilization, massage, exercises, and physical agents to aid the patient in achieving their maximum potential within their capabilities and to accelerate convalescence and reduce the length of functional recovery. All procedures will be thoroughly explained to you before you are asked to perform them.

    Chiropractic care involves what is known as a chiropractic adjustment. There may be additional supportive procedures or recommendations as well. When providing an adjustment, we use our hands or an instrument to reposition anatomical structures, such as vertebrae. As with all types of health care interventions, there are some risks to care, including, but not I im ited to: muscle spasms, aggravating and/or temporary increase in symptoms, lack of improvement of symptoms, burns and/or scarring from electrical stimulation and from hot or cold therapies, including but not limited to hot packs and ice, fractures (broken bones), disc injuries, strokes, dislocations, strains, and sprains. With respect to strokes, there is a rare but serious condition known as an "arterial dissection" that typically is caused by a tear in the inner layer of the artery that may cause the development of a thrombus (clot) with the potential to lead to a stroke. The best available scientific evidence supports the understanding that chiropractic adjustment does not cause a dissection in a normal, healthy artery. Disease processes, genetic disorders, medications, and vessel abnormalities may cause an aI1ery to be more susceptible to dissection.

    Response to care and interventions varies from person to person; hence, it is not possible to accurately predict your response to a specific modality, procedure, exercise protocol, or treatment. Advanced Healthcare of the Palm Beaches, Inc. does not guarantee what your reaction will be to a specific treatment, nor does it guarantee that the treatment will help resolve the condition that you are seeking treatment for. Furthennore, there is a possibility that the care may result in aggravation of existing symptoms and may cause pain or injury.

    It is your right to decline any part of your treatment at any time before or during treatment, should you feel any discomfort or pain or have other unresolved concerns. It is your right to ask your doctor or healthcare provider about the treatment they have planned based on your individual history, diagnosis, symptoms, and examination results. Consequently, it is your right to discuss the potential risks and benefits involved in your treatment.

    I have read, or have had read to me, the above consent I appreciate that it is not possible to consider every possible complication to care. I have also had an opportunity to ask questions about its content, and by signing below, I agree with the current or future recommendation to receive treatment as is deemed appropriate for my circumstance. I intend this consent to cover the entire course of care from all providers in this office for my present condition and for any future condition(s) for which I seek treatment from this office.

    I agree to settle any claim or dispute I may have against or with any of these persons or entities, whether related to the prescribed care or otherwise, will be resolved by binding arbitration under the current malpractice terms which can be obtained by written request.

    PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

    I acknowledge that I have reviewed the Notice of Privacy Practices of ADVANCED HEALTHCARE OF
    THE PALM BEACHES, (AHC).

    Please initial below:


    Signature of Patient/Guardian


    Date


    Witness (Office Staff)


    Date

    X-ray Questionnaire: For women only


    Assignment of Insurance Benefits, Release & Demand

    Insurer and Patient Please Read the Following in its Entirely Carefully!

    I, the undersigner patient/insured knowingly, voluntarily and intentionally assign the rights and benefits of my automobile insurance a/k/a Personal Injury Protection (hereinafter PIP), and Medical Payments policy of insurance to the above health care provider. I understand it is the intention of the provider to accept this assignment of benefits in lieu of demanding payment at the time of services are rendered. I understand this document will allow the provider to file suit against an insurer for payment of the insurance benefits or an explanation of benefits and to seek 627.428 damages from the insurer. If the provider's bills are applied to a deductible, I agree this will serve as a benefit to me and I authorize and request such litigation. This assignment of benefits includes the cost of transportation, medications, supplies, over due interest and any potential claim for common law or statutory bad faith/unfair claims handling. If the insurer disputes the validity of this assignment of benefits, then the insurer is instructed to notify the provider in writing within five days of receipt of this document. Failure to inform the provider shall result in a waiver by the insurer to contest the validity of this document. The undersigned directs the insurer to pay the health care provider the maximum amount directly without any reductions & without including the patient's name on the check. To the extent the PIP insurer contends there is a material misrepresentation on the application for insurance resulting in the policy of insurance is declared voided, rescinded or canceled. I, as the named insurer under said policy of insurance, hereby assign the right to receive the premiums paid for my PIP insurance to this provider and to file suit for recovery of the premiums. The insurer is directed to issue such a refund check payable to this provider only. Should the medical bills not exceed the premium refunded, then the provider is directed to mail the patient/ named insured a check which represents the difference between the medical bills and the premiums paid.

    Disputes:

    The insurer is directed by the provider and the undersigned to not issue any checks or drafts in partial settlements of a claim that contain or are accompanied by language releasing the insurer or its insurer or its insured/ patient from liability unless there has been a prior written settlement agreed to by the health provider (Specifically the office manager) and the insurer as to the amount payable under the insurance policy. The insurer and the provider hereby contests and objects to any reductions or partial payments. Any partial or reduced payment, regardless of the accompanying language, issued by the insurer and deposited by the provider shall be done so under protest, at the risk of the insurer and the deposit shall not be deemed a waiver, accord, satisfaction, discharge, settlement or agreement by the provider to accept a reduced amount as payment in full. The insurer is hereby placed on notice that this provider reserves the right to seek the full amount of the bills submitted. Any effort by the insurer to pay a disputed debt as full satisfaction must be mailed to the address above, after speaking with the office manager, and mailed to the attention of the Office Manager. See 673.3111.

    EUOs and IMEs:

    If the insurer schedules a defense examination or examination under oath (hereinafter "EUO") the insurer is hereby INSTRUCTED to send a copy of said notification to this provider. The provider or the provider's attorney is expressly authorized to appear at any EUO or IME set by the insurer. The health care provider is not the agent of the insurer or the patient for any purpose.

    This assignment applies to both past and future medical expenses and is valid even if undated. A photocopy of this assignment is to be considered as valid as the original. I agree to pay any applicable deductible, co-payments, for services rendered after the policy of insurance exhausts and for any check for services rendered by the above provider; and to request and obtain a copy of any statements or examinations under oath given by patient.

    Release of information:

    I hereby authorize this provider to: furnish an insurer, an insurer's intermediary, the patient's other medical providers, and the patient's attorney via mail, fax or email, with any and all information that may be contained in the medical records; to obtain insurance coverage information (declaration sheet & policy of insurance) in writing and telephonically from the insurer; request from any insurer all explanation of benefits (EOBs) for all providers and non-redacted PIP payout sheets; obtain any written and verbal statements the patient or anyone else provided to the insurer; obtain copies of the entire claim file and all medical records, including but not limited to, documents reports, scans, notes, bills, opinions, X-rays, IMEs and MRls, from any other medical provider or any insurer. The provider is permitted to produce my medical records to its attorney in connection with any pending lawsuits. The insurer is directed to keep the patient's medical records from this provider private and confidential and the insurer is not authorized to provide these medical records to anyone without the patient's and provider's prior express written permission.

    Demand:

    Demand is hereby made for the insurer to pay all bills within 30 days without reductions and to mail the latest non-redacted PIP payout sheet and the insurance coverage declaration sheet to the above provider within 15 days. The insurer is directed to pay the bills in the order they are received. However, if a bill from this provider and a claim from anyone else is received by the insurer on the same day the insurer is directed to not apply this provider's bill to the deductible. If a bill from this provider and claim from anyone else is received by the insurer on the same day then the insurer is directed to pay this provider first before the policy is exhausted. In the event the provider's medical bills are disputed or reduced by the insurer for any reason, or amount, the insurer is to: set aside the entire amount disputed or reduced; escrow the full amount at issue; and not pay the disputed amount to anyone or any entity, including myself, until the dispute is resolved by a Court. Do not exhaust the policy. The insurer is instructed to inform, in writing, the provider of any dispute.

    Certification:

    I certify that: I have read and agree to the above; I have not been solicited or promised anything in exchange for receiving health care; I have not received any promises or guarantees from anyone as to the results that may be obtained by any treatment or services and I agree the provider's prices for medical services, treatment and supplies are reasonable, usual and customary.

    Caution:

    Please read before signing. Please ask to view a copy of the charges. If you do not completely understand this document please ask us to explain It to you. If you sign below we will assume you understand and agree to the above.

    Standard Disclosure and Acknowledgement Form
    Personal Injury Protection - Initial Treatment or Service Provided

    I . The services or treatment set forth below were actually rendered. This means that those services have already been provided.

    2. I have the right and the duty to confirm that the services have already been provided.

    3. I was not solicited by any person to seek any services from the medical provider of the services described above.

    4. The medical provider has explained the services to me for which payment is being claimed.

    5. If I notify the insurer in writing of a billing error, I may be entitled to a portion of any reduction in the amounts paid by my motor vehicle insurer. If entitled, my share would be at least 20% of the amount of the reduction, up to $500.

    The undersigned licensed medical professional or medical director, if applicable, affirms the statement numbered 1 above and also:

    A. I have not solicited or caused the insured person, who was involved in a motor vehicle accident, to be solicited to make a claim for Personal Injury Protection benefits.

    B. The treatment or services rendered were explained to the insured person, or his or her guardian, sufficiently for that person to sign this form with informed consent.

    C. The accompanying statement or bill is properly completed in all material provisions and all relevant information has been provided therein. This means that each request for information has been responded to truthfully, accurately, and in a substantially complete manner.

    D. The coding of procedures on the accompanying statement or bill is proper. This means that no service has been upcoded, unbundled, or constitutes an invalid or not medically necessary diagnostic test as defined by Section 627.732(14) and (15), Florida Statutes or Section 627.736(5)(b)6, Florida Statutes.

    Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of Claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree per section 817.234(1)(b), Florida Statutes.

    Note:The Original of this form must be furnished to the insurer pursuant to section 623.736(4)(b), Florida Statutes and may not be electronically furnished. Failure to furnish this form may result is non-payment of the claim.

    Standard Disclosure and Acknowledgement Form
    Personal Injury Protection - Initial Treatment or Service Provided

    I . The services or treatment set forth below were actually rendered. This means that those services have already been provided.

    2. I have the right and the duty to confirm that the services have already been provided.

    3. I was not solicited by any person to seek any services from the medical provider of the services described above.

    4. The medical provider has explained the services to me for which payment is being claimed.

    5. If I notify the insurer in writing of a billing error, I may be entitled to a portion of any reduction in the amounts paid by my motor vehicle insurer. If entitled, my share would be at least 20% of the amount of the reduction, up to $500.

    The undersigned licensed medical professional or medical director, if applicable, affirms the statement numbered 1 above and also:

    A. I have not solicited or caused the insured person, who was involved in a motor vehicle accident, to be solicited to make a claim for Personal Injury Protection benefits.

    B. The treatment or services rendered were explained to the insured person, or his or her guardian, sufficiently for that person to sign this form with informed consent.

    C. The accompanying statement or bill is properly completed in all material provisions and all relevant information has been provided therein. This means that each request for information has been responded to truthfully, accurately, and in a substantially complete manner.

    D. The coding of procedures on the accompanying statement or bill is proper. This means that no service has been upcoded, unbundled, or constitutes an invalid or not medically necessary diagnostic test as defined by Section 627.732(14) and (15), Florida Statutes or Section 627.736(5)(b)6, Florida Statutes.

    Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of Claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree per section 817.234(1)(b), Florida Statutes.

    Note:The Original of this form must be furnished to the insurer pursuant to section 623.736(4)(b), Florida Statutes and may not be electronically furnished. Failure to furnish this form may result is non-payment of the claim.