New Patient Health History Form

PATIENT INFORMATION

Whom may we thank for referring you? 

PHONE NUMBERS

IN CASE OF EMERGENCY, CONTACT:

INSURANCE 

ASSIGNMENT AND RELEASE/ AUTHORIZED SIGNATURE

and assign directly to Moss Chiropractic Clinic all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am I financially responsible for all charges whether or not the insurance agrees to pay or if they deny the claims. 

I hereby authorize the release of any medical information necessary to process this claim and request payment of insurance benefits either to myself or to the party who signs below. I authorize the use of this signature on all insurance submissions.

ACCIDENT INFORMATION

Please be sure to give the receptionist a copy of your Insurance Card(s) and Drivers License.

CURRENT SYMPTOM LIST

PATIENT CONDITION 

CURRENT HEALTH HISTORY 

PREGNANCY DISCLAIMER: 

PAST HEALTH HISTORY 

Please mark any conditions that you currently have or conditions that you have had in the past.

Other Symptoms:

Please list any accidents or falls and the date of the incident:

OPERATIONS AND PROCEDURES

Input dates on the following if you had undergone operations and procedures

SOCIAL HISTORY/HABITS

FAMILY HISTORY

AUTHORIZATION AND ASSIGNMENT

In consideration of you providing care for me, I agree to the following:

1. You are authorized to release any information you deem appropriate concerning my physical condition to any insurance company, attorney or adjuster in order to process any claim for reimbursement of charges incurred.

2. I authorize the direct payment to you of any sum I now or hereafter owe you by my attorney, out of the proceeds of any settlement of my case, and by any insurance company obligate to make payment to me or you based in whole, or in part, upon the charges made for your services.

3. In the event any insurance company obligated by contractual agreement to make payment to me, or to you, for the charges made for your services refuses to make such payment upon demand by you, 

I hereby assign and transfer to you the cause of action that exists in my favor against any such company (the name (s) of which is believed to be correctly set forth under pertinent data) and authorize you to prosecute said action either in my name as you see fit and further authorize you to compromise, settle or otherwise resolve said claim as you see fit. 

It is understood, however that all reasonable efforts have been made to collect the sums due from the insurance company or companies contractually obligated, you will refrain from attempt and efforts to collect the amounts owed directly from me. I understand that whatever amounts you do not collect from insurance companies proceeds, whether it be all or part of what is due, I personally owe you.

4. In addition to the above, I hereby waive the statue of limitations on collection and/or recovery in this state of Florida.

5. I further agree that this Authorization is irrevocable until all monies owed Moss Chiropractic Clinic are paid in full.

RECORDS RELEASE

I have read and understand the above Financial Policy. I authorize the Doctor to examine and treat my condition as deemed appropriate through the use of Chiropractic Health Care, and I give authorization for these procedure to be performed. 

The amount paid to the Doctor’s office for X-rays is for the examination only; the X-ray negatives will remain the property of the Doctor’s office and will remain on file at the Doctor’s office as long as I am a patient. I am the responsible party for payment of any treatment received or incurred on this account. This Doctor provides only chiropractic care and is not responsible for any pre-existing medically diagnosed conditions or for making any medical diagnosis.