New Patient Registration - WholeHealth Chicago · Our Integrative Health Consultation (IHC) fee,...

New Patient Registration

TODAY’S DATE: PATIENT INFORMATION Last Name: _________________________________________________ First Name:_______________________________ Middle Name:_______________ Street Address:______________________________________________________________ City:__________________ State:___________ Zip:___________ Home Telephone: _______________________________ E-Mail: ________________________________________ Fax #:______________________________ Cell Phone:_______________________________________ Secondary E-Mail: _________________________________________________________________ Birthdate: _____/_____/_____Age: ______ Social Security #: _______- ________- _______Gender: __________________Married: Y N Occupation:_____________________________ Student: Y or N Full time:_____ Part time:______ Work Telephone : ___________________________ Employer Address: ___________________________ City:_____________________________ State:____________ Zip:_________________

RESPONSIBLE PARTY INFORMATION Last Name: _________________________________________________ First Name:_______________________________ Middle Name:_______________ Street Address:______________________________________________________________ City:__________________ State:___________ Zip:___________ Home Telephone: _______________________________ E-Mail: ____________________________________________________________________________ Birthdate: ______/ ______/ _______Age: _________ Social Security #: ________- ______- ________Gender: ____________________________ Occupation: _________________________________Relationship to Patient: Self ______Spouse ______Partner ______ Dependent ______ Employer: ____________________________________________________________________________ Work Telephone: _____________________________ Employer Address: ___________________________________ City:_________________________ State:_______ Zip:_______________

INSURANCE INFORMATION

_______________________________________________________________ _______________________________________________________________ Primary Insurance Secondary Insurance _______________________________________________________________ _______________________________________________________________ Address Address ______________________________ ________________ ______________ ______________________________ ________________ ______________ City State Zip City State Zip __________________________________________________ ____________ __________________________________________________ ____________ Insured Name Date of Birth Insured Name Date of Birth __________________________________ ___________________________ __________________________________ ___________________________ Policy I.D. # Group #: Policy I.D. # Group #:

OTHER INFORMATION

Illness/Injury is job related: Yes _______ No ________ Illness/Injury related to an accident?: Yes _______ No ________

If yes, Date of Injury:____________________________________________ If yes, Date of Accident: __________________________________________

Employer: ____________________________________________________ Do you have an attorney?: Yes _______ No ________

Employer Contact: _____________________________________________ Attorney Name: _________________________________________________

Employer Phone # _____________________________________________ Attorney Phone #: _______________________________________________ How did you hear about our office: Yellow Pages ______ Personal Reference (Name):________________ Other:__________________

IN CASE OF EMERGENCY Name: __________________________________ Relationship: _________________ Address: _____________________________________________________ City: _________________________________________ State: ___________ Zip: ______________ Telephone #: _____________________________________

PRIMARY HEALTH CONCERN: _________________________________________________________________________________________________________ I HEREBY CERTIFY THAT THE INFORMATION GIVEN ABOVE IS TRUE AND CORRECT. I UNDERSTAND THAT REGARDLESS OF INSURANCE COVERAGE, I AM ULTIMATELY RESPONSIBLE FOR ALL SERVICES PERFORMED.

_______________________________________________________________________

PATIENT SIGNATURE OR RESPONSIBLE PARTY SIGNATURE

_____________________________________________________

DATE

2265 NORTH CLYBOURN AVENUE • CHICAGO, IL 60614 • P: 773.296.6700 • F: 773.296.1131 • WWW.WHOLEHEALTHCHICAGO.COM

New Patient Intake Form To our new patients: Welcome to WholeHealth Chicago, Inc! To help us establish you with our practice, please complete the following form. This form has been designed to facilitate our patients’ continuity of care at Whole Health Chicago, Inc. This is a confidential record and will be kept in this facility. Information contained here will not be released to anyone without your authorization to do so.

TODAY’S DATE: PERSONAL HISTORY FORM Name: __________________________________________________ Date of Birth: ____/____/_____ Age: _____ Gender: ____________________________

Address:______________________________________ City:__________________ State: ________ Zip: ___________ Phone#: ________________________

Date of Last Physical Exam: ______________ Your Doctor: ________________________________ Referred by: ____________________________________

ALLERGIES: _________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________

MAIN PROBLEMS/ REASONS FOR THIS APPOINTMENT: (if possible, rank in terms of importance to you) 1. __________________________________________________________________________________________________________________________________

2. __________________________________________________________________________________________________________________________________

3. __________________________________________________________________________________________________________________________________

4. __________________________________________________________________________________________________________________________________

5. __________________________________________________________________________________________________________________________________

Please mark your areas of pain/

discomfort on the figures:

Is your condition getting worse? Yes _______ No ________ Is your discomfort Constant _______ or Off and On _______ Have you seen other doctors for these conditions? Yes _______ No ________ (If yes, please list doctor, prior interventions, treatments medication and treatment dates.) _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________

Have you experienced any accidents or falls within the: Past Year _______ Past 5 Years _______ Never _______

(If you have experienced an accident, what type was it? Auto _______ Work _______ Home _______ Sports _______ Other _______

Briefly explain: _______________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

HEALTH SCREENING HISTORY

List the date of your most recent test or exam.

Mammogram: ________________ Pap Smear: ________________ Self Breast Exam: ________________ Breast Exam by Doctor: _________________

Blood test for Anemia: _______________ Blood test for Cholesterol: _________________ Other Blood Tests: __________________________________

Immunizations: Polio: ___________ Tetanus: ______________ Hepatitis: _______________ Pneumonia: ______________ Flu Shot: _______________

Test for Blood in stool: _____________ Rectal Exam: ______________ Feeling the Prostate: ______________ Scope Lower Bowel: ______________

Self Exam Testicle: ________________ Testicle Exam by Professional: ___________________________ P: _________________ G: _________________


New Patient Intake Form

Patient Name: __________________________________________________

CURRENT MEDICATIONS DOSE TIMES / DAY

_________________________________________________________________________ __________________________ __________________________

_________________________________________________________________________ __________________________ __________________________

_________________________________________________________________________ __________________________ __________________________

_________________________________________________________________________ __________________________ __________________________

CURRENT HERBS/VITAMINS/SUPPLEMENTS DOSE TIMES / DAY

_________________________________________________________________________ __________________________ __________________________

_________________________________________________________________________ __________________________ __________________________

_________________________________________________________________________ __________________________ __________________________

_________________________________________________________________________ __________________________ __________________________

PAST MEDICAL HISTORY (Prior Illness, Injury, Hospitalization, Surgery, Trauma)

Date: _________________ Reason: __________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________

PERSONAL AND FAMILY HISTORY: (check all those that apply) YOURSELF MOTHER FATHER GRANDPARENT SIBLING SPOUSE CHILDREN AIDS ALCOHOLISM ALLERGIES ALZHEIMERS ANEMIA ARTHRITIS ASTHMA BREAST CANCER CANCER COLON CANCER DEPRESSION DIABETES DRUG ABUSE EMPHYSEMA EPILEPSY GLAUCOMA HEART ATTACK HEART TROUBLE HIGH BLOOD PRESSURE IRRITABLE BOWEL SYNDROME KIDNEY DISEASE LIVER DISEASE MENTAL ILLNESS MIGRAINE HEADACHES PNEUMONIA PROSTATE CANCER SICKLE CELL ANEMIA STROKE SUICIDE THYROID DISEASE TUBERCULOSIS ULCERS



Patient Name: __________________________________________________ PATIENT REPORTS (Symptoms that Currently Apply to You) CONSTITUTIONAL EAR, NOSE, MUSCLES, BONES DIGESTION & EYES IMMUNE SYSTEM BLOOD SYSTEM MOUTH & THROAT & JOINTS INTESTINE

Poor Appetite _____ Headaches _____ Neck Pain _____ Indigestion _____ Blurred Vision _____ Too Many Anemia _____

Fevers _____ Jaw Clicks _____ Back Pain _____ Belching _____ Eye Pain _____ Infections _____

Easy Bruising _____ Allergies to

Chills _____ Grinding Teeth _____ Muscle Pain _____ Heartburn _____ Poor Vision: Chest Pain _____ Food _____

Food Cravings _____ Trouble Painful Joints: Difficulty Day _____ Night _____

Allergies to Lightheaded _____ Wear Corrective

Weight Loss _____ Chewing _____ Right _____ Left _____ Swallowing _____ Environment _____

Palpitations _____ Facial Pain _____ Shoulder _____ Nausea _____

Lenses _____ Lymph Gland

Weight Gain _____ Nearsighted _____ Cold Hands Sore Throat _____ Elbow _____ Liver Trouble _____

Swelling _____

Fatigue _____ Farsighted _____ Other _____ or Feet _____

Mouth Sores _____ Hip _____ Vomiting _____ Fainting _____

Other _____

Bad Breath _____ Knee _____ Diarrhea _____

Swelling Feet _____

Ringing Ears _____ Ankle _____ Cramping Bowels _____ Blood Clots

Nosebleed _____ Wrist _____ Gassy Gut _____ Varicose Veins _____

Postnasal Drip _____ Finger _____ Constipation _____

Sinus Problems _____ Joint Swelling _____ Abdominal Pain _____

Trouble with Muscle Weakness _____ Rectal Pain/Itching _____ Taste/Smell _____

Muscle Cramps _____ Hemorrhoids/

Poor Hearing _____

Piles _____

Earaches _____ Blood in Stool _____

BREATHING & LUNGS SEXUAL ORGANS SKIN, HAIR, BREAST NERVES, BRAIN, WOMEN URINE, KIDNEY & REPRODUCTIVE & MOVEMENT BLADDER

Shortness of Sores on Breast Lumps Seizures _____ Pelvic Pain _____ Painful Age Period Breath _____ Genitals _____ or Pain _____

Nerve Pain _____ Vaginal Urination _____ Started _____

Wheezing or Lumps or Breast Leaks Wake up Number of Poor Balance _____

Discharge _____ Asthma _____ Swelling _____ Fluid _____

Painful Periods _____ to Urinate_____ Pregnancies _____

Repeated Colds Erection Rashes _____ Poor Kidney Stones _____ Pregnancies Premenstrual or Flu _____ Problems _____

Itching/Hives _____ Coordination _____

Loss of Bladder Lost _____

Cough, Dry/ Poor Sexual Tremors or Syndrome _____

Past Fertility Hair Loss _____ Hot Flashes _____

Control _____ Irritating _____ Response _____ Shaking _____

Frequent Problems _____

Infertility _____ Dry Skin,

Itching or Number of Live Urination _____

Repeated Eczema _____ Soreness _____

Sudden Urge Births _____

Children, Currently Infections _____ to Urinate _____

Blood/Puss in Living _____

Age Menopause _____ Urine _____



Patient Name: __________________________________________________

SOCIAL HISTORY (Check those that apply)

MARITAL STATUS: Single _____ Married _____ Divorced _____ Other ______________________

EDUCATION LEVEL COMPLETED: High School _____ College _____ Professional School _____ Other _______________________

MEMORIES OF YOUR CHILDHOOD: Mostly Happy _____ Mostly Painful _____ Normal _____ Don’t Recall _____

DO YOU FIND YOUR LIFE: Generally Unsatisfactory _____Too Demanding _____ Boring _____ Satisfactory _____

LIVING ARRANGEMENT: Alone _____ Family _____ Roommate _____ Other ________________________________

CHILDREN (list ages): ______________________________________________________________________________________________________________

MAJOR STRESSES IN LAST SIX MONTHS: Money _____ Job _____ Marriage _____ Home Life _____ Children _____

Other _____________________________________________________________________________________________________________________________

LIFESTYLE / SELF CARE ISSUES

Do you smoke cigarettes? Yes _____ No _____ If yes, how many? _________ Packs per day

Did you ever smoke? Yes _____ No _____ If yes, when did you quit? _______________

Do you drink alcohol? Yes _____ No _____ If yes, how much? ________ Drinks per week

Do you drink caffeinated beverages? Yes _____ No _____ If yes, which? ________________________________________________

Do you use recreational drugs? Yes _____ No _____ If yes, which? ________________________________________________

Do you manage stress well? Yes _____ No _____ Not Sure _____ Need Help _____

Do you exercise regularly? Yes _____ No _____ If no, why? ___________________________________________________

Do you enjoy your job? Yes _____ No _____ If no, why? ___________________________________________________

Do you allow time to unwind and relax? Yes _____ No _____ If no, why? ___________________________________________________

Do you sleep soundly? Yes _____ No _____ If no, why? ___________________________________________________

Are you satisfied with your sex life? Yes _____ No _____ If no, why?___________________________________________________

Are you satisfied with your social life? Yes _____ No _____ If no, why? ___________________________________________________

Are you satisfied with your spiritual life? Yes _____ No _____ If no, why? ___________________________________________________

Is your diet healthy enough? Yes _____ No _____ Not Sure _____ Need Help _____

TYPICAL BREAKFAST: ______________________________________________________________________________________________________________

TYPICAL LUNCH: __________________________________________________________________________________________________________________

TYPICAL DINNER: _________________________________________________________________________________________________________________

TYPICAL SNACKS: _________________________________________________________________________________________________________________

DEVICES

Do You Use: Eyeglasses _____ Contact Lenses_____

Brace (Neck, Back) _____ Pacemaker _____

Hearing Aid_____

IUD, Diaphragm_____

Dentures _____

Artificial Limbs _____

YOUR PRIMARY CARE DOCTOR’S NAME _____________________________________DR’s PHONE #__________________________________ YOUR PRIMARY CARE DOCTOR’S ADDRESS _________________________________________________________________________________________ May we contact your regular or referring doctor? _________________________________________________________________________________________

I HAVE REVIEWED AND CONFIRMED THE INFORMATION WITH THE PATIENT. _______________________________________________________________________

PHYSICIAN SIGNATURE

_____________________________________________________

DATE 2265 NORTH CLYBOURN AVENUE

• CHICAGO, IL 60614

• P: 773.296.6700

• F: 773.296.1131

• WWW.WHOLEHEALTHCHICAGO.COM

Our Financial Policy WHOLEHEALTH CHICAGO 3, SC OUR FINANCIAL POLICY Thank you for choosing WholeHealth Chicago as your health care center. We are committed to the success of your treatment and care. Please understand that a mutual financial understanding is part of our relationship. We sincerely hope that by sharing our financial expectations we will strengthen the practitioner-patient relationship and keep the lines of communication open. This financial policy helps us provide quality care to our valued patients. Payment is Due at the Time of Service. • We accept cash, checks, debit and credit cards as forms of payment. • All co-payments, deductibles, co-insurance and fees for non-covered services, including the Integrative Health Consultation (IHC) fee, are due at the time of service. • We send appointment reminders, via e-mail, three days before your appointment. We request that at least 48 hours advance notice be given to the office if you will be

unable to keep your scheduled appointment. This allows us to release your appointment time to another patient. Since we do not double book our appointments and reserve the appointment time exclusively to you, we charge the full amount of the visit for no-shows (see chart below) to the credit card on file. Patients who repeatedly “no show” for appointments may be discharged from the practice.

Health Insurance • We are in-network with BCBS PPO and Blue Choice Select PPO plans. Our Integrative Health Consultation (IHC) fee, homeopathic consultations,

acupuncture, massage therapy, healing touch, vitamin therapy, intravenous therapy, and any purchases made in the Natural Apothecary are non-covered services and are due at the time of service.

• We are out-of-network with all other health insurance plans and payment is due in full at the time of service.

• We do not accept any HMO plans, Medicaid or Medicare (exceptions for Medicare include chiropractic manipulation only, psychotherapy (Dr. Janet Chandler) only. You will be considered a self-pay patient.

• It is your responsibility to notify us of changes in your health insurance, address and phone number. Fees

Practitioner New Patient** Established Patient**

Medical Physicians and Nurse Practitioners $325 $195 § Lyme Patients (scheduled for 2 hrs) $725 $425

Chiropractic Physicians $195-260 40 min $125 20 min $90

Clinical Psychology $270 $210 Nutritionists* $300 $175 Yoga Therapy* $90-135 $90-135 Homeopathic Medicine* $245 $170 Traditional Chinese Medicine/Acupuncture* $130 $80 Healing Touch* $165 $110

* Services indicated by an asterisk are considered “non-covered services” and are due at the time of service. ** Amounts are for professional fees only. Labs, tests, vitamin therapy, intravenous therapy, and supplements are additional fees.


Billing, Payments and Refunds

• WholeHealth Chicago will issue a refund if there is an overpayment on your account only if there are no outstanding debts on other accounts with the same guarantor or financial responsible party.

• We reserve the right to report delinquent accounts to credit bureaus, assess a collection fee, take other collection action, or terminate you as a patient of WholeHealth Chicago.

• I authorize WholeHealth Chicago to charge the credit card on file for the amount plus a $25 fee for checks returned for insufficient funds.

• WholeHealth Chicago will automatically charge $25 to the credit card on file for the following: health insurance “pre-authorizations” for procedures, requested letters from providers, health insurance request forms, mailed prescriptions, and e-mails requiring medical decision making.

• WholeHealth Chicago will charge my credit card for services not reimbursed by my insurance company after 60 days.

• I choose to have balances not covered by my insurance CHARGED automatically ( ) OR ( ) MAIL statements to me before charging my credit card so that I have the opportunity to pay by check. I understand that if this payment is not received within three (3) weeks of the statement date, the balance due will be charged to the credit card provided. If no option is selected, my full balance will be charged to the credit card below. WholeHealth Chicago will automatically charge any statement balance amounts $25 and under.

Credit Card on File I authorize WholeHealth Chicago to maintain the following credit card on file. This credit card will be charged in the event of a "No Show" for an appointment; defined as not canceling or rescheduling my office appointments and/or procedures within 48 hours.

I authorize WholeHealth Chicago to charge this credit card for any outstanding balances on my account

This authorization is valid until I provide you with written cancellation.

Credit Card___ Debit Card___ HSA___

Visa___ MasterCard___ Discover___ Amx___ CareCredit___

_________________________________ ________________________________ ________________________________

Name on Credit Card (Patient or Relationship) Last 4 Digits of Credit Card Number Expiration Date and CVN Security Code

___________________________________________________________________________________________________________

Credit Card Billing Address (Street, Apt #, City, State, Zip)

______ Initial

I have read, understand and agree to the above Financial Policy. I understand that charges not reimbursed by my health insurance company, as well as applicable co-payments and deductibles, are my responsibility.

______ Initial

In-Network Insurance: I authorize my health insurance benefits be paid directly to WholeHealth Chicago. If I receive reimbursement directly from BCBS for services not paid to WholeHealth Chicago, I will endorse that check and submit to WholeHealth Chicago within five (5) business days. Otherwise, I authorized WholeHealth Chicago to collect the full amount of my account balance using the credit card on file. In the event my claim is denied, I authorize WholeHealth Chicago to file an appeal on my behalf.

______ Initial

Notice of Coverage: I have been informed by WholeHealth Chicago in advance that the following services are not covered under my health insurance contract, deemed not medically necessary or are considered to be experimental or investigational: Integrative Health Consultation (IHC) fee, homeopathic consultations, acupuncture, healing touch, vitamin therapy, intravenous therapy, and any purchases made in the apothecary. I understand and agree that I am responsible for payment of the charges for these services at the time of service.

I have read, understand, and agree to this Financial Policy. _______________________________________________________________________

SIGNATURE

_____________________________________________________

DATE

Relationship to patient (if minor) ___________________________________________

Privacy Policy & Informed Consent

With patient consent, WholeHealth Chicago may use and disclose protected health information to carry out treatment, payment, and healthcare operations only. Please refer to WholeHealth Chicago’s Notice of Privacy Practices for a complete description of such uses and disclosures, available at the front desk.

WholeHealth Chicago will do its best to protect your private health information while allowing you access to your records. • WholeHealth Chicago will not sell your information to any third parties for marketing purposes.• WholeHealth Chicago will not release your information for any purposes without your signed consent.• You have the right to review your medical records and make amendments to those records. Records may be obtained by

submitting a written request.• You have the right to submit a written request that WholeHealth Chicago restrict how it uses or discloses your protected health information.• You may revoke this consent in writing except to the extent that the practice has already made disclosures with this prior consent.

Please initial where you consent to the following:

______ WholeHealth Chicago may call my home, or another designated number and leave a message, recorded or with a person, regarding items that assist the practice in carrying out treatment, payment, and operations.

______ WholeHealth Chicago may mail to my home or other designated location any items that assist the practice in carrying out treatment, payment, and operations.

______ WholeHealth Chicago may e-mail to my home or other designated location any items that assist the practice in carrying out treatment, payment, and operations.

Informed Consent _____ I authorize WholeHealth Chicago, through its appropriate personnel, to perform or have performed upon me, appropriate assessment and treatment procedures. Many of the therapies offered at the Center are considered alternative and may be deemed “unproven” or “experimental” by the insurance industry or FDA. There is no obligation to accept or complete any therapeutic recommendation. _____ I authorize WholeHealth Chicago permission to view my prescription medication records in order to provide appropriate treatment. _____ I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Burns and/or scarring are a potential risk of moxibustion and cupping, or when treatment involves the use of heat lamps. Bruising is a common side effect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage, and organ puncture, including pneumothorax (lung puncture). Infection is another possible risk, although the Center uses sterile disposable needles and maintains a clean and safe environment. _____ I authorize WholeHealth Chicago to contact or discuss my personal health information with:

Name _____________________________________________ Relationship __________________________________

Patient signature ______________________________________________________ Date __________________________

I have read the WholeHealth Chicago Privacy Policy and Consent to Treatment and thoroughly acknowledge, understand, and agree to all of the above information.

Name ________________________________________ Signature _____________________________________________

Date ___________________ Relationship to patient (if minor) _________________________________________


E-MAIL CORRESPONDENCE POLICY (WHEN UTILIZING THE PATIENT PORTAL)

WholeHealth Chicago has recently experienced an extraordinary increase in the number of e-mails received by our providers. We will now be charging a nominal fee of $25 for some e-mail communications requiring significant medical decision-making, requests for therapeutic advice, a change to the treatment plan, or a prescription request. Simple inquiries regarding how to take a medication, requesting a referral, etc. will not be charged. Most health insurance companies do not yet reimburse for e-mail correspondence; therefore, you will be responsible for this fee. The credit card on file will be charged for this service. The Patient Portal is available to you as an optional service; This service will allow you to:

• securely and privately communicate with your providers • receive and access lab results • request prescription refills

_________________________________________________ ____________ Signature Date

2265 NORTH CLYBOURN AVENUE ·CHICAGO, IL 60614 · P:773.296.6700 · F:773-296-1131 · WWW.WHOLEHEALTHCHICAGO.COM

New Patient Registration - WholeHealth Chicago · Our Integrative Health Consultation (IHC) fee,...

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