authorization to disclose protected health information

3 LOCATIONS TO SERVE YOU BETTER!
WELCOME
PINES WEST CHIROPRACTIC EAST SIDE CHIROPRACTIC MARTINEZ CHIROPRACTIC
18501 Pines Blvd., Suite 104
8228 Biscayne Blvd.
12595 S.W. 137 Ave., Ste 108
Miami, FL 33029
Miami, FL 33138
Miami, FL 33186
PATIENT INFORMATION
PHONES NUMBERS
Home: _ _ _ _ __ __
Work: _ _ _ _ _ _ __
Ext: _ _ _ _ _ _ __
Patient: - - - -- - - - - - -- -- - - - - Date: _ _ _ _..:.,___-""
Address:--- - -- - - - - -- -- - - - - - - -- -- - ' - - City: _ _ _ _ _ _ _ _ _ __ State: _ _ _ _ Zip Code: _ _ _ _ _....:..,_....:...
Sex: OM OF
Age: _ _ _ _ _ __ _ DOB: _ _ _ _ _ _ _ __
Best time to call _ _ _ __
0 Single
D Married
D Widowed
D Divorced
Patient SS No. _ _ __ __ _ _ ___ Occupation: _ _ _ _ _ _ _ _ __
Employer
Employer Phone No. _ __ __
Cell Phone: _ _ _ _ __
Email: _ _ _ __ __ _
Employer Address: - - - - - - - - - - -- - - - - - - ---:-,...:.....__ _
Spouse's Name:
Birthdate: ------,-:..-....:..:___ _
Patient SS No.
Occupation:- - - --......,:.::..__.:.......::.__:___
Spouse's Employer: _ __ __ _ __ __ __ _ _ _ _ _ ___.:..._~-~:........:--:
IN CASE OF EMERGENCY
Name: _ _ _ _ _ __ __
Relationship: _ __ _ __
Home#: _ _ _ _ _ __
Work: _ _ _ _ _ _ __
Primary Care Physician:
Phone Number: ----'-:---..::::._~-=..:..-'----'
Whom may we thank for referring you: - - - -----------,.-,--"'-::,..--,:---:--:---
INSURANCE .
·.
·
. ..
.
.
.
·
Who is responsible for this account? ----------:-'----'=-''---':---'---~
Relationship to Patient ------------::-::-~-=-:-:-=-=----=-:-:---=~
Insurance Co. Name -----------~----=--?-7:"+-:+---:=-:-:----:~
Group or Card No. - - - - -- ----------...,...,...-=-,...-=-+Is Patient covered by additional insurance
D Yes
Subscriber's Name-- - - - - - -- - - - - - - - - - - Birthdate
SS No. ~,-,---.......,..,..--,-,.....,.,-:,---,---­
Relationship to Patient ----~-----::..,.--~-::-~..:....:,:..,......:.:..,.-----­
Insurance Co. Name -----:--""':-"--.-:---:-..:.,__-~~-7----:-=-:-:-----­
lnsurance I.D. No. ----......;..,--=.....:~....:..._____.:_...:.....;_;..:---:---'-------
PATIENT CONDITION
·
ACCIDENT INFORMATION
Is condition due to an accident?
DYes D No
Date _ _ _ _ ___
Type of Accident?
D Auto
D Work
D Home
0 Other
Explain Other: _ _ _ _ _ _ _ __
If yes, please tell our front office and fill out
correct accident form in addition to this form.
_
.
Reason for Visit:
Preventive health check up: D Yes
0 No
When did your symptoms appear?
Is condition getting progressively worse?
D Yes
D No
0 Unknown
Mark an x on the picture where you continue to have pain, numbness or tingling - - - - -- - - - - Rate the severity of your pain on a scale of 1 (least pain to 10 (server pain) _ _ _ _ __ __ _ _ __
Type of Pain: D Sharp D Dull D Throbbing 0 Numbness 0 Aching D Shooting
D Burning
D Tingling D Cramps
D Stiffness
D Swelling
0 Other
How many days in the last week did you feel the pain?
D Is it constant or D Occasional
Does it interfere with your D Work
D Family Life
D Sleep
D Recreation
D Exercise
Activities or movements that are painful to perform D Sitting D Standing D Walking D Bending D Lying Down D Driving
Do~u s~erkoma~otherh~~cond~on~---------------------~----
PAST HEALTH HISTORY
Please Check and Describe:·- - -- - - - - -- - - - - -- - - - - - - - - - -- - - - -Major Surgery/Operations: D Appendectomy D Tonsillectomy
D Gall Bladder
D Hernia
D Back Surgery
0 Broken Bones 0 Other---- - -- - - - - - - -- - -- - -- - - - -- - - -- Car accidents, falls, i~uries: -------------------------------~
Hosp~al~ationiDtherThanAbove): _ _ __ _ _ _ __ _
_ _ __ _ _ _ _ _ __ __ _ __ _ _ __
Previous Chiropractic Care:
D None D Doctor's Name & Approximate Date of Last Visit _ _ __ _ _ __ _ _ __
Drugs You Now Take: D Nerve Pills D Pain Killers/ Muscle Relaxers 0 Blood Pressure Medicine
D Insulin
OOther - - - - -- - - - - - - - - - - - - - - - - - - - -- - - - - -- - - - -
Below are a list of diseases which may seem unrelated to the purpose of your appointment. However the questions must be
answered carefully as these problems can affect your overall course of chiropractic care.
CHECK ANY OF THE FOLLOWING DISEASE YOU HAVE HAD OR CURRENTLY HAVE:
0 Pneumonia
OAicoholism
0 Thyroid
0 Mental Disorders
D Pacemakers
0 Rheumatic Fever
D Mumps
0 Asthma
0 Lumbago
0 Multiple Sclerosis
D Polio
0 Small Pox
D Aids/H.I.V.
0 Eczema
0 Psychiatric Care
0 Tuberculosis
0 Chicken Pox
0 Influenza
0 Stroke
D Hepatitis
0 Whooping Cough
0 Diabetes
0 Pleurisy
0 Osteoporosis
0 Hernia
0 Anemia
0 Cancer
0 Arthritis
0 Weak Immune System
0 Carpal Tunnel Synd.
0 Epilepsy
0 Measles
D Heart Disease
0 Subluxations
0 Repetitive Strain Synd.
0 Chemical Dependency
CHECK ANY OF THE FOLLOWING YOU HAVE HAD THE PAST SIX MONTHS:
MUSCULO-SKELETAL CODE
GASTRO-INTESTINAL CODE
NERVOUS SYSTEM CODE
0
0
D
0
0
0
0
0
0
D
0
0
0
0
Low Back Pain
fla~n Between Shoulders
Neck Pain
Arm Pain
Joint Pain/Stiffness
Shoulder Pain
Knee Pain
Hip Pain
Hand/Wrist Pain
Foot/Ankle Pain
D
D
D
0
0
0
0
0
0
0
GENERAL CODE
0
0
D
0
D
Fatigue
Allergies
Loss of Sleep
Fever
Headaches
0
0
0
0
0
0
0
0
0
0
Chest Pain
Shortness of Breath
Blood Pressure
Irregular Heartbeat
Heart Problems
Lung Problems/Congestion
Varicose Veins
Ankle Swelling
Stroke
0
0
0
0
0
0
Bladder Trouble
Painful/Excessive Urination
Discolored Urine
0
0
0
0
Vision Probers
Dental Problems
Sore Throat
Ear Aches
Hearing Difficulty
Stuffed Nose
FAMILY HISTORY
MALE/FEMALE CODE
0
0
0
Nervous
Numbness
Paralysis
Dizziness
Forgetfulness
Confusion/Depression
Fainting
Convulsions
Cold/Tingling Extremities
Stress
EENTCODE
GENITO-URINARY CODE
D
0
0
C-V-R CODE
0
0
0
D
0
0
0
0
0
Poor/Excessive Appetite
Excessive Thirst
Frequent Nausea
Vomiting
Diarrhea
Constipation
Hemorrhoids
Liver Problems
Weight Trouble
Abdominal Cramps
Gas/Bloating After Meals
Heartburn
Black/Bloody Stool
Colitis
Menstrual Irregularity
Menstrual Cramps
Vaginal Painjlnfection
Breast Pain/Lumps
Prostate/Sexual Dysfunction
Venereal Disease
Other Problems _ _ _ _ _ _ __
The following members have the
same or sim1lar problems as I do:
0 Mother
0 Father
0 Brother
0 Sister
0 Spouse
0 Child
FEMALES ONLY
0 Yes
When was your last menstrual cycle? _ _ _ _ _ _ Are you pregnant?
EXERCISE
WORK ACTIVITY
HABITS
D
D
0
0
0
0
0
0
0
0
O
None
Moderate
Daily
Heavy
0
Sitting
Computers
Standing
Light Labor
Heavy Labor
0
Smoking
Alcohol
Coffee/Caffeine Drinks
High Stress Level
0 No
0 Not Sure
Packs/Day _ _ _ __
Drinks/Week _ _ __
Cups/Day _ _ _ __
What is most important in your Doctor/Patient relationship?---- - -- - - - - - - - - - - - - - - - - - What are your health goals?
0 pain relief only
0
correct my health problem
Signature - -- -- - - - - - - - - - - -
Dr. Damian Martinez ● Dr. Damaris Sabater ● Dr. Thomas Krahn
AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION
I authorize Martinez Chiropractic Center and any member of its staff to call, leave voice mail messages
and\e-mail messages and disclose Protected Health Information (PHI) pertaining to me, including but not
limited to medical information, such as test results, procedures results, appointment reminders, or any
other PHI related to my treatment to the following numbers:
○ Home Number
○ Cell Phone Number
○ Work Number
○ Email
Appointment Reminders:
○Text Message
Cell Phone Company: _____________
○Email _______________________
○No Reminder
All reminders are sent approximately
24 hours prior to your appointment.
I authorize Martinez Chiropractic Center and any member of its staff to fax my (PHI), including medical
information needed for my treatment to the following fax number: ____________________________.
I authorize Martinez Chiropractic Center and any member of its staff to disclose my (PHI), including test
results to the following individuals:
Name: _______________________________ Relationship: _________________________
Name: _______________________________ Relationship: _________________________
Name: _______________________________ Relationship: _________________________
____________________________________
Patient Signature
_________________________
Date
Martinez Chiropractic Center ● 12595 SW 137 AVE STE108 ● Miami, FL 33186
Office (305)-388-7577 ● Fax (305) 388-7851
Dr. Damian Martinez ● Dr. Damaris Sabater ● Dr. Thomas Krahn
RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGMENT
FORM
I, _______________________________ have received a copy of Martinez Chiropractic Center
Notice of Patient Privacy Practices.
INFORMED CONSENT FORM
I, ______________________________________hereby request and consent to the performance
of chiropractic treatments and other chiropractic/medical procedures, including various forms
of physical therapy and diagnostic x-rays by Martinez Chiropractic Center. This consent is
extended to other licensed chiropractic Physicians, Chiropractic assistants or licensed Massage
Therapists, who now or in the future, are employed by, working with or associated with this
office.
I certify that I have had the opportunity to discuss, with the doctor of Chiropractic and/or other
office personnel, the nature and purpose of the care that is being provided. I understand that
the results are not guaranteed. Further, I have been informed and I understand that, as in the
practice of any of the healing arts, in the practice of Chiropractic, there are some risks to
treatment including, but not limited to, fractures, disc injuries, strokes, dislocations and sprains.
I also understand that the doctor, who has explained all of these things to me, is not expecting
to be able to anticipate and explain all the risks and complications. I will rely on the doctor to
exercise appropriate judgment during the course of care, based on the facts known at this time,
and in my best interest.
My signature below certifies that I have read, or have had read to me the above consent. I also
certify that I have had the opportunity to ask questions and options to care have been
explained. By signing this consent form, I agree to the care being provided to me for the entire
course of treatment for my present condition(s) and for any future condition(s) for which I seek
treatment.
My signature certifies that I have read and agreed to what has been stated above.
_______________________________
Patient Signature
_____________
Date
Martinez Chiropractic Center ● 12595 SW 137 AVE STE108 ● Miami, FL 33186
Office (305)-388-7577 ● Fax (305) 388-7851
Dr. Damian Martinez ● Dr. Damaris Sabater ● Dr. Thomas Krahn
No Accident Form
I, ____________________ am seeking care from Martinez Chiropractic Center. The treatment
is not due to a work related injury, automobile accident, or slip and fall.
AUTHORIZATION
I hereby authorize payment of benefits due to me from my insurance company and/or attorney
to be made directly to Martinez Chiropractic Center. I further authorize the release of any
medical records required by my insurance carrier. I fully understand that I am financially
responsible for any charges covered by this authorization to Martinez Chiropractic Center. In the
event that it becomes necessary to institute litigation over the non-payment of our fees, the
cost and legal expenses incurred therein are that of the patient.
Insurance Certification
This is to certify that I, _____________________________________ have presented any and all
information regarding my health insurance plan(s).
The only health insurance policy in effect is:
Name of Insurance Co._________________________________________
Insured’s Name_______________________________________________
Relationship with Insured_______________________________________
ID#___________________________ Group#______________________
My signature certifies that the information I have filled in above is accurate, and that I am not
seeking care due to an auto accident, work injury, or slip & fall nor do I have an open or pending
case.
___________________________ ______________________________
Patient’s Signature
Print Patient’s Name
_______________________
Date
Martinez Chiropractic Center ● 12595 SW 137 AVE STE108 ● Miami, FL 33186
Office (305)-388-7577 ● Fax (305) 388-7851