Martin & Schrage Chiropractic 10.2016

Martin & Schrage Chiropractic

Office of Dr. Leslie Martin & Dr. Jennifer Howard

3675 N 129th Street | Omaha, NE 68164

Pediatric Intake Form

Child Legal Name First MI Last Address

City State Zip Code

Cell Phone Home Phone ___________________________________

Text Message Appointment Reminders: Yes | No if YesCell Phone Carrier: Sprint | Verizon | AT&T | ____________

Secure Patient Portal Access: Please list your preferred email address to be used to register you for our secure

patient portal. Once registered you will be sent an email with directions on how to complete the registration

process. You will be required to change your password upon logging in. This portal will give you access to Visit

Summaries, Vitals and Direct Secure Messaging with your provider.

Email Email is used to set up electronic portal for patient access and to communicate with patient. We do not sell your information.

Patient Identification: *******************ALL INFORMATION REQUIRED************************

Date of Birth: Age Gender (check one) Male Female Unspecified

Marital Status (check one) Single Married Other Spouse Name:_________________________

Patient SSN (minimum last 4 digits)

How did you hear about our office? Whom may we thank for your referral? (check one)

Family Member* Internet Web Site Other Chiropractor Google

Attorney* Sign on Building Yellow Book Yahoo

Friend* Insurance Website Dex Phone Book Bing

Physician* Direct Mail Other* YELP

*Please Describe __________________________________________

Employment Status: (check one)

Employed FT Student PT Student Other Retired Self Employed

Employer Name: __________________________________________ Phone: _________________________

Insured Data Policy Holder: (check one if filing to insurance)

Self Spouse Parent Other Employee

Insured’s Name: _______________________________________ Date of Birth

Secondary Insurance Insured’s Name: ____________________ Date of Birth / /

Emergency Contact

Name: Phone:

Relation (check one) Sibling Parent Friend Employee

/ /

- -

/ /

Martin & Schrage Chiropractic 10.2016

AUTHORIZATION FOR CARE OF MINOR

I hereby authorize this office and its doctor to administer care as they so deem necessary to my son/daughter/ward (Upon

approval of parent or guardian.)

Signed: Date:

I realize that I am responsible for all fees charged by this office and I agree to pay for all services provided.

Signed: Date:

Current medications (this includes any non-prescription or homeopathic vitamins or supplements)

If there are no current medications, check here:

1) 5)

2) 6)

3) 7)

4) 8)

List any known allergies you have had to any medications and interaction.

If no allergies are known, check here:

1) 3)

2) 4)

Third Trimester Presentation

Vertex Breech Transverse Face/Brow

Type of Birth

Normal Vaginal Forceps Cesarean Suction Cap or Vacuum

Location: Home Birthing Center Hospital

Problems during Pregnancy:

Problems during Labor/Delivery:

Congenital anomalies/defects:

Infant Habits

Feeding: Breast Bottle

Number of hours sleeping per night: ______________________________ Quality of sleep? Good Fair Poor

At what age did the child:

Respond to sound ________________ Follow an object with his/her eyes ________________ Hold Head Up _________________

Sit Alone _________________ Crawl _________________ Stand ___________________ Walk Alone _________________

At what age, if ever, did your child suffer from the following diseases?

Chickenpox _______________ Mumps _______________ Measles _________________ Rubella ________________

Rubeola ________________ Whooping Cough _________________ Other______________________________________________________

Martin & Schrage Chiropractic 10.2016

Has the child ever suffered from?

Headaches Dizziness Fainting Seizures/Convulsions Heart Trouble Neck Problems

Chronic Earaches Sinus Trouble Asthma Colds/Flu Colic Orthopedic Problems

Arm Problems Leg Problems Joint Problems Backaches Poor Posture Scoliosis Walking Trouble

Broken Bones Digestive Disorders Poor Appetite Stomach aches Reflux Constipation Diarrhea Hypertension

Anemia Bed Wetting Behavioral Problems ADD/ADHD Ruptures/Hernia Muscle Pain Growing Pains

Other ______________________________________________________________________________________________________________________________________________

Has the child ever suffered from the following spinal trauma?

Fall in baby walker Fall from crib Fall from high chair Fall from changing table Fall from bed or couch Fall off swing

Fall off slide Fall off monkey bars Fall off skateboard or skates Fall off bicycle Fall down stairs Other__________________

Has this child ever sustained an injury from playing organized sports? ______________ If yes, Please Explain:

Has this child ever sustained injuries in an auto accident? _____________ If yes, Please Explain:

Present History:

Surgery:

Accidents/Injuries:

Family History:

Reason for today’s visit: :

To Be Performed by Clinic Staff: Date______________ Staff ___________________

Height _____________ Weight _____________ Blood Pressure ______/________ Pulse ____________

Martin & Schrage Chiropractic 10.2016

Martin & Schrage Chiropractic

3675 N 129th Street Omaha, NE 68164

www.AbsoluteOmahaChiropractic.com

www.mcwomaha.com

INFORMED CONSENT TO CHIROPRACTIC ADJUSTMENTS AND CARE

I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of

physiotherapy and diagnostic x-rays, on me (or on the patient named below, for whom I am legally responsible) by the doctor of chiropractic named

above.

I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment including, but not

limited to, fractures, disc injuries, strokes, dislocations and sprains. It is not reasonable to expect the doctor to be able to anticipate and explain all risks

and complications of a given procedure on any particular visit, and I wish to rely on the doctor to exercise judgment during the course of the procedure

which the doctor feels at the time, based upon the facts then known, is in my best interests.

Chiropractic treatment involves the science, philosophy and art of locating and correcting spinal misalignments and as such, is oriented toward

improvement of spinal function relative to range of motion, muscular and neurological aspects. There has been no promise, implied or otherwise, of a

cure for any symptom, disease or condition as a result of treatment in this clinic. I understand that the chiropractor will use her hands or a mechanical

device upon my body to adjust a joint, which may cause an audible “pop” or “click.”

INFORMED CONSENT TO ACUPUNCTURE TREATMENT AND CARE

I hereby request and consent to the performance of acupuncture treatments and other complementary medicine procedures including various modes of

physiotherapy on me (or on the patient named below, for whom I am legally responsible) by the above named licensed Chiropractor.

I understand that methods or treatment may include, but are not limited to, acupuncture with needles, moxabustion, electrical stimulation of the

acupuncture point, or manual stimulation of the acupuncture point.

Acupuncture attempts to normalize physiological functions, to modify the perception of pain, and to treat certain diseases of dysfunctions of the body. I

have been informed that acupuncture is a safe method of treatment, but occasionally there may be some bruising or tingling near the needling sites that

last a few days. There have been very rare instances reported of fainting, infection and scarring. There have been extremely rare instances reported of

spontaneous miscarriage and pneumothorax.

I understand that as part of my healthcare, this Practice originates and maintains health records describing my health history, symptoms,

examination and test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves as a basis for

planning my care and treatment; a means of communication among other health professionals who may contribute to my care; a source of information

for applying my diagnosis and treatment information to my bill; and a means by which a third-party payer can verify that services billed were actually

provided.

I have read, or have had read to me, the Informed Consent. I have also had an opportunity to ask questions about its content, and by signing below I

agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future

condition(s) for which I seek treatment.

INFORMED CONSENT TO THIRD PARTY PAYER

I understand that as part of my healthcare, this Practice originates and maintains health records describing my health history, symptoms, examination and

test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves as a basis for planning my care and

treatment; a means of communication among other health professionals who may contribute to my care; a source of information for applying my diagnosis

and treatment information to my bill; and a means by which a third-party payer can verify that services billed were actually provided.

I have read, or have had read to me, the Informed Consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to

the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for

which I seek treatment.

__________________________________________________________ ______________________

Signature: Patient or Legal Representative (Attorney, Guardian, Parent) Date Signed

Martin & Schrage Chiropractic 10.2016

HIPAA Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY.

Uses and Disclosures: We will use and disclose elements of your protected health information (PHI) in the following ways: Without your signed authorization: • Treatment • Payment • Health care operations • When release is required by law, including in judicial settings and to health oversight regulatory agencies and law enforcement. • In emergency situations or to avert serious health/safety situations. • To medical examiners, coroners or funeral directors to aid in identifying you or to help them in performing their duties. • To organ, tissue and other donation organizations, upon or proximate to your death if you have no indication on hand about your donation preferences. Special cases • To contact you about appointment reminders, treatment alternatives and other health related benefits and services. • To the sponsor of your health plan. Other • All other uses and disclosure by us will require us to obtain from you a written authorization in addition to any other permission you will provide us. Your rights: You have the following rights concerning your PHI: Restrictions: To request restricted access to all or part of your PHI. We are not required to grant your request. Confidential communications: To received correspondences of confidential information by alternate means or location. Access: To inspect or receive copies of your protected health information. Amendments: To request changes be made to your PHI. We are not required to grant your request. Accounting: To receive an accounting of the disclosure by us of your PHI in the six years prior to your request. This notice: To get updates or reissue of this notice, at your request. Complaints: To complain to us or the U.S. Dept. of Health & Human Services if you feel your privacy rights have been violated. The law forbids us from taking retaliatory action against you if you complain. Our Duties: We are required by law to maintain the privacy of your PHI. We must abide by the terms of this notice or any update of this notice. Martin & Schrage Chiropractic is in compliance with the HIPAA Omnibus Rule. Martin & Schrage Chiropractic will not disclose Private Health Information without authorized permission from a patient. Private Health Information would be used/disclosed with authorized permission for marketing purposes. If you do not give express permission, we will not use your information for marketing purposes. If a patient requests a digital copy of certain electronic Private Health Information or directs Dr. Martin or Dr. Howard in writing to transmit a copy to another person, Dr. Martin or Dr. Howard will produce the information in the format requested (if readily producible) within 30 days or negotiate an alternative format. Further, if a patient request that a copy of his or her Private Health Information be sent via unencrypted email, the Dr. Martin or Dr. Howard will be permitted to do so, providing that the patient is aware of the risks and prefers the unencrypted email. Please be aware that Dr. Martin or Dr. Howard has the means to send some Private Health Information via encrypted email. If a patient would prefer an encrypted email, please inform Dr. Martin or Dr. Howard or a Staff Member. As a patient, you have a right to restrict any disclosures made to health plans for payment or health care operations purposes if the Private Health Information pertains to an item or service for which you paid COMPLETELY out of pocket. Martin & Schrage Chiropractic has completed a Risk Assessment regarding Private Health Information and has found no breaches in security. If in the event a breach occurs Martin & Schrage Chiropractic will inform affected patients and perform another Risk Assessment to address any changes that need to be made. Martin & Schrage Chiropractic takes the protection of Private Health Information very seriously and maintains strict compliance with any and all HIPAA requirements. To read the HIPAA Omnibus Rule in its entirety and how it may pertain to you please visit: http://www.gpo.gov/fdsys/pkg/FR-2013-01-25/pdf/2013-01073.pdf By signing you are acknowledging that you have read the Update Privacy Policy.

_________________________________________________________________ ______________________

Signature: Patient or Legal Representative Date Signed

Martin & Schrage Chiropractic 10.2016

MARTIN CHIROPRACTIC & WELLNESS, & SCHRAGE CHIROPRACTIC PC 3675 N 129TH STREET OMAHA, NE 68164

402-614-8334 | 402-885-8783

Consent to use PHI

Acknowledgement for Consent to Use and Disclosure of Protected Health Information

Use and Disclosure of your Protected Health Information Your Protected Health Information will be used by Stafford Corp, dba Martin Chiropractic & Wellness, & Schrage Chiropractic PC or may be disclosed to others for the purposes of treatment, obtaining payment, or supporting the day-to-day health care operations of this office.

Notice of Privacy Practices You should review the Notice of Privacy Practices for a more complete description of how your Protected Health Information may be used or disclosed. It describes your rights as they concern the limited use of health information, including your demographic

information, collected from you and created or received by this office. Initial One I have RECEIVED a copy of the Notice of Patient Privacy Policy. ______Patient Initials

I have DECLINED a copy of the Notice of Patient Privacy Policy. ______Patient Initials

Requesting a Restriction on the Use or Disclosure of Your Information • You may request a restriction on the use or disclosure of your Protected Health Information.

• This office may or may not agree to restrict the use or disclosure of your Protected Health Information.

• If we agree to your request, the restriction will be binding with this office. Use or disclosure of protected information in violation of an agreed upon restriction will be a violation of the federal privacy standards.

Notice of Treatment in Open or Common Areas Therapy services may be provided in a common room with more than one patient receiving treatment at a time. Chiropractic care and acupuncture along with examinations are performed in private rooms.

Revocation of Consent You may revoke this consent to the use and disclosure of your Protected Health Information. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected.

By my signature below I give my permission to use and disclose my health information.

Patient or Legally Authorized Individual Signature Date

Print Patient’s Full Name Time

Witness Signature Date

Martin & Schrage Chiropractic 10.2016

Financial Policy Insurance Coverage

Welcome to Martin & Schrage Chiropractic. Your insurance policy is an agreement between you and

your insurer, not between your insurer and this clinic. Like all types of care, coverage for chiropractic

services varies from insurer to insurer and plan to plan. Most insurance policies require the beneficiary

to pay co-insurance, co-payment and/or a deductible. For example: if you have a deductible of $100, and

your insurance pays 80%, you are responsible for 20% of all charges incurred during the year after you

have paid your $100 at the beginning of the year. Our clinic will call your insurer to verify your benefits;

however, we are not responsible for your insurer’s final payment and benefit determinations.

Payment Options

In order to help you determine your responsibility toward payment for services, please read the following, and initial your preference for the method of payment of your account. Please notify this office

if the status of your insurance changes.

Choose ONE Option A-F CASH: A I want to pay with CASH or CREDIT for each treatment. As I have no insurance, I agree to assume all responsibility and to keep my account current by paying for services when they are rendered. B I have insurance, but I wish to file my claims personally, and I agree to assume all responsibility and to keep my account current by paying for each visit at the time services are rendered. Health Insurance: C I would like this clinic to bill my insurance. I understand I am responsible for the costs of treatment including deductible, co-pays or co-insurance. Personal Injury: D______I want to use my Med Pay – Insurance through my own auto insurance coverage. Med pay will pay your bill as you go, and be reimbursed from the at-fault insurance when you settle. If your med pay insurance is exhausted before your treatment is complete, then the at-fault insurance company will be billed. E_____ I want to use my personal insurance. (If you are a Blue Cross Blue Shield participant you must choose this option as they require all claims be sent directly to them). F_____ I want to pay with CASH or CREDIT for each treatment. I understand that I can turn the receipt of payment into my Med-Pay or At-Fault for reimbursement when I settle.

I understand that all health services rendered to me and charged to me are my personal financial responsibility. I understand and agree to the conditions of this policy.

Signature Date

Martin & Schrage Chiropractic 10.2016

Appointment Policy

Our goal is to provide quality individualized care in a timely manner. "No-shows" and late cancellations inconvenience those

individuals who need access to care in a timely manner. We would like to remind you of our office policy regarding missed

appointments. This policy enables us to better utilize available appointments for our patients in need of care.

Acupuncture appoints are structured appointments that are booked at a maximus of 6 appointments per day with a specific time just

for your appointment and cannot be filled at the last minute. Chiropractic appointments are scheduled every 15 minutes throughout

the day. For that reason, there is a missed appointment policy for services and we require at least 24 hours’ notice of cancellation or

rescheduling. Failure to do so will result in a missed appointment fee. This fee is not covered by insurance and will be your

responsibility. Forgetting your appointment or last-minute work or social obligations are not considered emergencies, so a missed

appointment fee will be charged to you in those circumstances in addition to no-shows.

Cancellation Policy In order to be respectful of other patient’s needs, please be courteous and call Martin & Schrage Chiropractic promptly if you are unable to show up for your appointment. Appointments are in high demand, and your early cancellation will be reallocated to someone who is in need of treatment. If you need to cancel an appointment, please do so at least 24 hours in advance. If you cancel less than 24 hours before your appointment you will be charged a fee for your missed appointment. Acupuncture - $36 Chiropractic - $20 Initial here: ______________ Late for your appointment If you are more than 15 (fifteen) minutes late for your appointment you may not be treated or you may receive an abbreviated treatment within the time constraints of your originally scheduled appointment. Initial here: ______________ Missed appointment or No-Show If you miss an appointment without calling to notify the office at least 24 hours in advance you will be charged the fee(s) as listed above. Initial here: ______________

How to Cancel Your Appointment

To cancel appointments, please call 402-885-8783 or 402-614-8334. If you do not reach the receptionist, you may leave a detailed

message on our voicemail. If you would like to reschedule your appointment, we will return your call and give you the next available

appointment time.

X__________________________________________________ __________________________________

Sign Date