Patient InformationFirst Name *Middle Name(s)Last Name *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Date of Birth *Birth MonthSelect month123456789101112DaySelect day12345678910111213141516171819202122232425262728293031Birth YearSelect Year212321222121212021192118211721162115211421132112211121102109210821072106210521042103210221012100209920982097209620952094209320922091209020892088208720862085208420832082208120802079207820772076207520742073207220712070206920682067206620652064206320622061206020592058205720562055205420532052205120502049204820472046204520442043204220412040203920382037203620352034203320322031203020292028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923Date of BirthGender *GenderMaleFemaleEmail Address *This is used for appointment reminders and correspondenceMobile Phone Number *Mobile Phone Number. This is used for appointment reminders and correspondenceSecondary Phone # (not required)Secondary Phone NumberSecondary Phone Type (not required)Secondary Phone TypeMobileHomeOfficeSymptomsWhat is your main complaint? *Please describe what caused your condition. *What is the condition a result of? *What is the condition a result of?UnknownJob relatedHome InjuryFallAuto AccidentSelect the INTENSITY of your PAIN when present: *Select One:0123456789100=no pain, 10=severe painDescribe the FREQUENCY of your PAIN: *Select One:Intermittent (0-25%)Occasional (25-50%)Frequent (50-75%)Constant (75-100%)Describe the Pain (Mark All That Apply): *DullTight/stiffAcheSharpSpasmNumbnessTinglingThrobbingBurningCrampingShootingOther Conditions in the Past 6 Weeks *NoneHeadachesNeck PainPain Between ShouldersLow Back PainShoulder Joint PainElbow PainWrist PainHip Joint PainKnee PainAnkle/Foot PainArm and/or Hand is Numb and/or TinglingLeg and/or Foot is Numb and/or TinglingThe neck pain is on: *Left SideRight SideBoth SidesPlease select oneThe lower back pain is on: *Left SideRight SideBoth SidesPlease select oneThe shoulder joint pain is on: *Left SideRight SideBoth SidesPlease select oneThe elbow pain is on: *Left SideRight SideBoth SidesPlease select oneThe wrist pain is on: *Left SideRight SideBoth SidesPlease select oneThe hip joint pain is on: *Left SideRight SideBoth SidesPlease select oneThe knee pain is on: *Left SideRight SideBoth SidesPlease select oneThe ankle/foot pain is on: *Left SideRight SideBoth SidesPlease select oneThe Arm and/or Hand Numbness and/or Tingling is on: *Left SideRight SideBoth SidesPlease select oneThe Leg and/or Foot Numbness and/or Tingling is on: *Left SideRight SideBoth SidesPlease select onePersonal InformationMarital Status *Marital StatusMarriedSingleMarital StatusSocial Security NumberOccupation *EmployerNumber of Hours Worked per WeekEmergency Contact First and Last NameEmergency Contact Phone NumberEmergency Contact's Relationship to PatientFamily Doctor NameFamily Doctor Phone (not required)Insurance InformationPlease provide the name of your health insurance company provider as well as the policy/member id # and the phone number listed on your insurance card to allow our billing team to look up your policy coverage for our services. If the policy is under a different family member, please also include their name and date of birth. Please note that we are not responsible for the accuracy of the information we receive from the insurance company as to policy benefits, copays, co-insurance, and deductibles. At your report of findings, typically on your second follow up visit, the doctor will discuss in detail the results of the exams and imaging as well as the proposed care plan that incorporates insurance benefits and any out-of-pocket expenses.Name of Insurance CompanyInsurance Policy ID #Member/Subscriber's Last, First NameMember/Subscriber's Date of BirthMonthSelect month123456789101112DaySelect day12345678910111213141516171819202122232425262728293031YearSelect Year212321222121212021192118211721162115211421132112211121102109210821072106210521042103210221012100209920982097209620952094209320922091209020892088208720862085208420832082208120802079207820772076207520742073207220712070206920682067206620652064206320622061206020592058205720562055205420532052205120502049204820472046204520442043204220412040203920382037203620352034203320322031203020292028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923Member/Subscriber's Date of BirthRelationship to Subscriber (spouse, child)Insurance Phone # (optional)Agreements and DisclosuresPlease review carefully before signing.X-ray Consent:The purpose of the x-ray examination to be performed is to analyze the spine for evidence of vertebral subluxation, rate and level of degeneration of the spine, and to determine the appropriateness of spinal adjustments. If the doctor discovers a non-chiropractic “unusual finding” when reviewing the x-rays, I will be informed. With the help of the doctor, I thus must determine if I should seek the services of an additional healthcare provider for advice, diagnosis, or treatment of the unusual finding. I understand that seeking advice from another healthcare provider will likely not interfere with the subluxation correction care provided by this office. I fully understand the above and consent to chiropractic spinal x-rays.X-ray Consent: *I have read and understood the X-ray Consent. Please select one: *I AM or MAY be PREGNANTI am NOT PREGNANTPregnancy Release:This is to certify that to the best of my ability I am not pregnant, and I give my permission to perform an x-ray evaluation. I understand that there are potential risks to an unborn child of x-ray imaging, especially to the lumbo-pelvic region, and it is my responsibility to inform the doctor prior to any x-ray imaging.Pregnancy Release: *I have read and understood the Pregnancy Release HIPPA PrivacyThis office is required by law to maintain the privacy and confidentiality of your protected health information. I release this office from all liability and give permission to use my first and last name for the purpose of speaking with me in the presence of others. I understand that I may request a detailed copy of the HIPAA privacy rule at any time.HIPAA Privacy Rule: *I have read and understood the HIPAA Privacy Rule Informed Consent to CarePlease review carefully before signing.Please select one: *I am the patientI am a Custodial Parent or Legal GuardianInformed Consent to Care *You or your parent/legal guardian are the decision maker for your health care. Part of our role is to provide you with information to assist you in making informed choices. This process is often referred to as "informed 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. We may conduct some diagnostic or examination procedures if indicated. Any examinations or tests conducted will be carefully performed but may be uncomfortable. Chiropractic care centrally 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. Potential benefits of an adjustment include restoring normal joint motion, reducing swelling and inflammation in a joint, reducing pain in the joint, and improving neurological functioning and overall well-being. It is important that you understand, as with all health care approaches, results are not guaranteed, and there is no promise to cure. As with all types of health care interventions, there are some risks to care, including, but not limited 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 artery to be more susceptible to dissection. Strokes caused by arterial dissections have been associated with over 72 everyday activities such as sneezing, driving, and playing tennis. Arterial dissections occur in 3-4 of every 100,000 people whether they are receiving health care or not. Patients who experience this condition often, but not always, present to their medical doctor or chiropractor with neck pain and headache. Unfortunately a percentage of these patients will experience a stroke. The reported association between chiropractic visits and stroke is exceedingly rare and is estimated to be related in one in one million to one in two million cervical adjustments. For comparison, the incidence of hospital admission attributed to aspirin use from major GI events of the entire (upper and lower) GI tract was 1219 events/ per one million persons/year and risk of death has been estimated as 104 per one million users. It is also important that you understand there are treatment options available for your condition other than chiropractic procedures. Likely, you have tried many of these approaches already. These options may include, but are not limited to: self-administered care, over-the-counter pain relievers, physical measures and rest, medical care with prescription drugs, physical therapy, bracing, injections, and surgery. Lastly, you have the right to a second opinion and to secure other opinions about your circumstances and health care as you see fit. 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. By my signature or that of my parent or legal guardian/custodian, I consent to receive examination and recommended chiropractic treatment as is deemed appropriate for my circumstance. I understand that my doctor will take time to answer any questions that I have about recommended treatment. 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 chiropractic care from this office.Signature *Please sign here.Your browser does not support e-Signature field.By signing you are acknowledging that you have read, understood, and agree to the informed consent to care.Financial Policy and Agreement– Elite Spine, PCPlease select one: *I am the patientI am a Custodial Parent or Legal GuardianFinancial Policy and AgreementFinancial Release and Assignment: Payment is expected on the date that services are rendered. If we are in-network with your insurance, any claims filing will be done on your behalf, but payment of any deductible and co-insurance will be expected on the date that services are rendered. Balance for services is the patient responsibility. I understand any outstanding accounts beyond 60 days may result in a 2% finance charge per month. If the account is sent to collections, any fees associated with the collection of charges will also be billed to the patient (according to Collection Agency fee amounts). I authorize the release of any information necessary to process my insurance claims and request payment be sent directly to my physicians. I, the undersigned, in consideration of the Office’s services, agree to the following terms: Definitions. In this Agreement, “Office” and “Clinic” shall refer to Elite Spine, PC dba of Simply Chiropractic located at 7465 E 82nd St, Indianapolis, IN 46256. “Financial Policy” or “Agreement” shall refer to this document. Authorization to Sign My Name on Payments; Transfer of Credit Balances. I authorize the Office to endorse or sign my name on any and all payments listing me as a payee which are received by the Office for payment of Charges incurred by me, my spouse or my dependents. In such cases, my printed name, followed by the phrase, “(by [Name of Office]),” shall serve as a properly authorized endorsement. I further authorize the Office to apply any credit balances on my Charges to any other outstanding Charges still owed by me, my spouse, or my dependents, regardless of whether these other Charges are related to my condition. Personal Responsibility for My Charges. I understand that I remain personally responsible for my Charges and that at any time, I can request a copy of my total Charges from the Office. Except where provided otherwise by law or by contract, I agree to pay the full amount of my Charges to the Office promptly upon its demand. I understand that the Office’s Assignment does not constitute an agreement by the Office to await payment of my Charges. I agree that any delay by the Office in making demand for payment, any delay in paying the full amount of my Charges, and any partial payments received by the Office towards my Charges, shall not constitute acceptance of any installment payment plan, shall not constitute a waiver of the Office’s right to receive payment-in-full promptly upon demand, and shall not constitute an “accord and satisfaction” of my Charges, regardless of any such terms or restrictions indicated on, or included with, any payments. I also agree that my account with your Office shall be construed as in “default” on the earlier of the following dates: (a) a Payer fails to pay any or all of the Charges in-full and directly to the Office upon receipt of those Charges within thirty (30) days or the period established by the earliest prompt pay deadline applicable to the Payer (whichever occurs later), (b) I do not pay any or all of the Charges in-full within fourteen (14) days of request, or (c) the Office attempts to charge my credit card in compliance with a written Payment Arrangement, but the charge is declined or not approved. Personal Responsibility for Verifying the Limitations in My Coverage; Financial Responsibility for Non-Covered Charges. I understand that in any given situation, a Payer may initially refuse to make payment to the Office, may delay payment for an indefinite or unreasonable amount of time, or may actually request a refund from the Office after making payment, and do so either in whole or in part with respect to any given Charge incurred at the Office (collectively, “Deny Payment”). For example (without limiting this Agreement), I understand that a Payer may Deny Payment, stating that the Charge is “not a covered benefit” under its policy or exceeds some other limitation. I further understand that a Payer may Deny Payment stating that the individual provider who actually renders the treatment or procedure is out-of-network. I also understand that a Payer may claim, based on internal criteria, that a particular Charge is or was not medically necessary or was not sufficiently documented, and should therefore be denied or downcoded. I also understand that a Payer may require certain Charges to be pre-certified or preauthorized. In the event that my condition arose from an accident, I further agree to the terms of the Office’s Auto / Work Comp Advance Beneficiary Notices as applicable. I understand that there may be many other situations where a Payer may Deny Payment based on a particular contractual term applicable to me or to the Office (collectively, “Terms of Non-Coverage”). To the extent permitted by law or by contract, I agree that I am solely and exclusively responsible for verifying all Terms of Non-Coverage prior to incurring any Charges at the office. I agree that if I have any questions about the Terms of Non-Coverage, I can request copies of the Office’s verification (e.g., eligibility, pre-authorization) forms to gain further understanding. I agree that should the Office assist me in any way in the verification, pre-authorization, or billing process, I assume the risk that the Payer and/or the Office may in my opinion not accurately understand and/or communicate the Terms of Non-Coverage and/or bill my Charges to my Payers. Should any Payer Deny Payment, or should any Payer be likely to Deny Payment as determined by the Office in its sole discretion, I agree that I am personally, fully, and immediately responsible for the portion of my Charges denied or likely to be denied. In no event shall I hold the Office responsible or liable in any of the foregoing instances. Direction to the Office to Apply the Lowest Mandatory Fee Reduction When Two or More Payers Are Involved. Unless otherwise agreed to in writing, I authorize the Office to submit my Charges, as well as a copy of the Assignment & Lien, to any and all Payers, not including in accident cases my health benefit plan or Medicare. Notwithstanding the foregoing, in the event that the Office determines in its sole discretion that it has any reasonable basis for either submitting or not submitting my Charges and/or other documentation to a Payer, I hereby authorize the Office to take such action without condition or restriction. I understand that some or all of these Payers may utilize fee schedules which (a) the Office has agreed to accept, directly with said Payers in writing, or (b) law expressly imposes on the Office to accept (collectively, “Mandatory Fee Reductions”). I further understand that the Mandatory Fee Reductions imposed on the Office with respect to one Payer may exceed the Mandatory Fee Reductions imposed on the Office with respect to another Payer. In such an event, I hereby authorize and direct the Office insofar as permitted by law to apply the lower of the two Mandatory Fee Reductions to its Charges. I further agree that in the special event that Mandatory Fee Reductions are imposed on the Office by virtue of laws which regulate or restrict “balance billing,” I hereby waive the application of such laws to the extent permitted by law. In the event that no Mandatory Fee Reductions are actually imposed on the Office with respect to a Payer, I authorize and direct the Office to collect up to its full Charges from such Payer. Miscellaneous Provisions. Except as provided in this paragraph, this Agreement shall not be modified or revoked without the expressed, written consent of the Office. I hereby revoke, with the Office’s consent, the terms of any previously signed documents, but only to the extent those terms conflict with the terms of this Agreement. I agree that each and every provision of this Agreement is reasonably necessary. However, should any provision of this Agreement be found to be invalid, illegal or unenforceable, or for any reason cease to be binding on any party hereto, all other portions and provisions of this Agreement shall, nevertheless, remain in full force and effect. This Agreement shall be governed under the laws of the state where the Office is located, and is performable in the county where the Office is located. In any action based upon this Agreement, I hereby consent to personal jurisdiction and venue of any court in said county and waive all objections based on improper jurisdiction, venue, or forum inconvenience. I further waive any statute of limitations which may apply in any action based upon this Agreement. I have reviewed the Office’s “Assignment & Lien”, Health Insurance Election, and, if applicable, Auto / Work Comp Advance Beneficiary Notices, and further agree to the terms and definitions set forth in these documents as applicable. Said documents are incorporated herein by reference. In the event that my condition is related to an accident, including without limit automobile accident, I understand that there will be an administrative fee necessary to cover the costs of verifying multiple Payers, filing and terminating liens, and submitting notices of same to Payers. I have read, understood, and agree to the terms of this Agreement.Financial Policy and Agreement *I have read and understood the Financial Policy and Agreement Patient's First and Last Name *Patient's Signature *Please sign here.Your browser does not support e-Signature field.By signing you are acknowledging that you have read, understood, and agree to the Financial Policy and Agreement.First Name of Custodial Parent or Legal Guardian, on Behalf of the Patient *Last Name of Custodial Parent or Legal Guardian, on Behalf of the Patient *Parent / Guardian's SignaturePlease sign here.Your browser does not support e-Signature field.By signing you are acknowledging that you have read, understood, and agree to the Financial Policy and Agreement.Submit FormPlease do not fill in this field.