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

    Información del Nuevo Paciente


    [radio* gender use_label_element default:1 "Masculino" "Femenino"]

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

    Cuestionario de Accidente

    COMPROBAR TODOS LOS QUE APLIQUEN

    CompletoExtensivoMínimoModerado

    Manejando o ParadoAutopistaCarretera de ciudadlnterseccionEn una RampaFuera de una RampaDoblando a la derechaDoblando a la lzquierda

    De frenteDerecha del frentelzquierda del frentelzquierda traseraDerecha traseraOtro

    lnclininada hacia delanteMirando al frenteMirando a la izquierdaMirando a la derecha

    ClaroNublado LloviznandoBrumosoTormentaSaleado

    Fue a la casaSiguio con sus diligenciasFue al hospital en ambulanciaFue llevado al HospitalManejo usted mismo al HospitalOtro

    Rayos-XMRICAT ScanPuntos

    LESIONES Y SINTOMAS

    Estuvo noqueado o inconscienteDolor de cabezaDificultad para caminarSueno de diaCambia en lose sentidos de Olfato o hablarDolor en la caraMareadoProblemas para escucharProblemas de memoriaMuy cansado o fatigadoDificultad para dormirAlteraciones visuales, vision borrosa or dobleEscena retrospective del accidenteProblemas para leer or escribirNausea/ vomitos

    Dolor al cerrar la bocaDolor al masticarDolor al hablar

    Dolor en el cuello que causa dolor de babezaDolor de cuello Dolor de cuello que baja hacia el lado DERECHO: HombreBrazoManoEspalda AltaDolor de cuello que baja hacia el lado IZQUIERDO: HombreBrazoManoEspalda Alta

    Dolor de homrosIZQUIERDODERECHOAMBOS

    DERECHOIZQUIERDOAMBOS

    DERECHOIZQUIERDOAMBOS

    DERECHOIZQUIERDOAMBOS

    DERECHOIZQUIERDOAMBOS

    Alta

    Medic

    Dolor en espalda alta que irradia hacia la costilla DERECHA.

    Dolor en la espalda que irradia hacia la costilla IZQUIERDA.

    DERECHAIZQUIERDAAMBROS

    GluteoPierna

    GluteoPierna

    DERECHOIZQUIERDOAMBOS

    SiNo

    SiNo

    Historia De Salud

    Marque los problemas medicos que haya tenido en el pasado:

    Ahora

    Pasado

    Ahora

    Pasado

    Ahora

    Pasado

    Diabetis

    Tiroide

    Osteoporosis

    Ulceras

    Coto

    Polio

    Reflujo gastrico/ GERD

    Rinones

    Fracturas

    Colitis/ IBD

    Pneumonia

    Multiple Esclerosis

    Enfermedades del corazon

    Tuberculosis

    Parkinson's

    Congestive Heart Disease

    Influenza

    Problemas de Prostata

    Blood Clots {DVT}

    Asma

    Desorden inmune

    Peripheral Vascular Disease

    Emfisema

    Migrana

    Stroke

    COPD

    Trastorno convulsive

    Marcapasos

    Bronquitis

    AIDS/HIV

    Alta Presion

    Higado

    Dependencia quimica

    Colesterol

    Osteoartritis

    Desordenes mentales

    Sangramiento

    Artritis reumatodea

    Depresion

    Anemia

    Gota

    Alcolismo

    CHECK ANY OF THE FOLLOWING DISEASES/ SYMPTOMS YOU HAVE HAD IN THE PAST SIX MONTHS:

    GENERAL

    OJOS

    HEMATOLOGIC/ LYMPH

    PIEL

    ENDOCRINO

    MUSCULOESQUELETAL

    GASTROINTESTINAL

    CARDIOVASCULAR

    OIDO/GARGANT A/NARIZ

    GENITOURINARY

    SYSTEMA NERVIOSO

    RESPIRACION

    PSIQUIATRIA

    SOLO MUJERES

    Yo certifico que la informaci6n que he proporcionado es verdadera y correcta. Yo entiendo que proveer informaci6n incorrecta puede ser peligroso a mi salud.

    CONSENTIMIENTO PARA EL TRATAMIENTO

    Usted es quien toma las decisions para su salud. Parte de nuestro papel es el de proporcionarle informacion para ayudarle a tomar decisiones informadas. Este proceso es a veces llamado "consentimiento informado" y envuelve su entendimiento y acuerdo a pesar de nuestras recomendaciones, los beneficios y los riesgos asociados con el tratamiento, alternativas, y el efecto potencial en su salud si usted decide no hacer el tratamiento. Es importante que uted entienda, como con todos los tratamientos de salud, que los resultados no son garantlzados, y no hay promesa
    para curar.

    El paciente que venga al doctor le da concentimiento y autoridad al doctor para cuidar de el deacuerdo con las pruebas, diagnosticos y analisis apropiadas. Es possible que hagamos algunos diagnosticos, examenes, y procedimientos clinicos que rara vez causan incomodidad. Estos son usualmente beneficiales y rara vez causan problemas. En raros casos, defectos fisicos subyacentes, deformidades o patologias, pueden hacer que el paciente sea susceptible de lesi6n. El medico o povedor medico, por supuesto, nova a proporcionar atencion medica espedfica, si el/ ella es consciente de que tal cuidado puede estar contraindicado. Es la responsabilidad del paciente que sea conocida o aprender a traves de procedimientos de cuidado de la salud de lo que el/ ella esta sufriendo de: defectos latentes patologicos, enfermedades o deformidades, que de otro modo no vendrian a la atencion del medico.

    La terapia fisica es para el tratamiento de enfermedades, lesiones y discapacidad mediante el examen, la evaluacion, el diagnostico, el pronostico y la intervencion mediante el uso de procedimientos de rehabilitacion, movilizacion, masaje, ejercicios y agentes ffsicos para ayudar al paciente a alcanzar su maximo potencial dentro de sus capacidades y acelerar convalecencia y reducir la duracion de la recuperacion funcional. Todos los procedimientos se explicaran a fondo antes de que usted se le pide que los realice.

    El cuidado quiropractico consiste en lo que se conoce como un ajuste quiropractico. Puede haber procedimientos adicionales de apoyo o recomendaciones tambien. Al proporcionar un ajuste, usamos nuestras manos o un instrumento para cambiar la posicion de las estructuras anatomicas, tales como vertebras. Al igual que con todos los tipos de intervenciones de atencion de la salud, existen algunos riesgos a la atencion, incluyendo, pero no limitado a: espasmos musculares, aumento agravantes y / o temporal de los sintomas, la falta de mejoria de los sintomas, quemaduras y / o cicatrices de la estimulacion electrica y las terapias de calor o frio, incluyendo pero no limitado a balsas de agua caliente y el hielo, fracturas (huesos rotes), lesiones de disco, golpes , luxaciones , torceduras y esguinces. Con respecto a los accidentes cerebrovasculares, hay una condicion rara pero grave conocida como una II diseccion arterial II que por lo general es causada por un desgarro en la capa interna de la arteria que puede provocar el desarrollo de un trombo (coagulo ) con el potencial de conducir a un golpe. La mejor evidencia cientifica disponible apoya el entendimiento de que ajustes quiropracticos no causa una diseccion en una arteria normal y saludable. Procesos de enfermedades, trastornos geneticos, medicamentos y anormalidades de los vasos pueden causar una arteria sea mas susceptible a la diseccion

    Respuesta a la atenci6n y las intervenciones varia de persona a persona; por lo tanto, no es posible predecir con precision su respuesta a una modalidad, procedimiento, protocolo de ejercicio, o tratamiento espedfico Advanced Healthcare of the Palm Beaches no garantiza lo que su reaccion sera a un tratamiento espedfico, ni garantiza que el tratamiento le ayudara a resolver la condicion para laque usted esta buscando tratamiento.
    Ademas, existe la posibilidad de que la atencion puede resultar en empeoramiento de los sintomas existentes y puede causar dolor o lesion

    Es su derecho de rechazar cualquier parte de su tratamiento en cualquier memento antes o durante el tratamiento , en caso de que sienta ninguna molestia o dolor o tienen otras preocupaciones no resueltas. Es su derecho de preguntar a su medico o proveedor de atencion medica sobre el tratamiento que han planeado basado en el historial, los resultados del diagn6stico, los sintomas y los examenes individuales En consecuencia, es su derecho a discutir los riesgos y beneficios potenciales involucrados en su tratamiento.

    He leido, o se me ha leido, el consentimiento anteriormente. Soy consciente de que no es posible tener en cuenta todas las posible complicaci6n a la atencion. Tambien he tenido la oportunidad de hacer preguntas acerca de su contenido, y mediante la firma a continuacion. Estoy de acuerdo con la recomendacion actual o futuro para recibir un tratamiento que se considere adecuada para mi circunstancia. Tengo la intencion de este consentimiento para cubrir todo el curso de la atenci6n de todos los proveedores en esta oficina para mi condici6n presente y para cualquier condicion ( s) futuro para el cual busco tratamiento de esta oficina

    Estoy de acuerdo para liquidar cualquier reclamaci6n o disputa que pueda tener en contra o con cualquiera de estas personas o entidades, ya sea en relaci6n con el cuidado prescrito o de lo contrario , sera resuelta por arbitraje vinculante en los terminos actuales de negligencia que se pueden obtener mediante solicitud por escrito.

    RECONOCIMIENTO DEL PACIENTE DE AVISO DE PRACTICAS DE PRIVACIDAD

    Yo reconozco que he revisado el lnforme de Privacidad de Advanced Healthcare de ADVANCED HEALTHCARE OF THE PALM BEACHES.


    Firma del Paciente/Guardian


    Fecha


    Testigo


    Fecha

    Questionario para Rayos-X: Solo para mujeres


    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. Hqwever, 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.