List any of the following problems in your near relatives below:
Diabetes, high blood pressure, high cholesterol, stroke, heart attack, tuberculosis, cancer, arthritis, kidney disease, anemia, allergies, asthma, headaches, epilepsy, mental illness, alcoholism, drug addiction.
Relationship: MOTHER
IF LIVING
IF DECEASED
Relationship: GRANDPARENTS
Relationship: SISTER
Relationship: BROTHER
Please go over the following list of medical problems and check only those that pertain to you now or in the past.
Instructions: The following scales have been designed to find out about your back pain and how it is affecting you. Please answer ALL THE SCALES, and mark the ONE number on EACH scale that best describes how you feel.
With permission from: Bolton JE, Breen AC; The Bournemouth Questionnaire: A short-form comprehensive outcome measure. T. Psychometric Properties in back pain patients JMPT 1999: 22 (9); 503-510.
By submitting this form, you are affirmatively acknowledging and agreeing to the terms and conditions outlined below. You are certifying that the information provided is accurate and truthful to the best of your knowledge. You are granting permission to Comprehensive Spine & Sports Center, MI (hereinafter referred to as 'clinic' and 'the clinic') and its associated health professionals to collect, use, and disclose your personal and medical information as necessary for your treatment and as described in this form. You are also acknowledging your understanding and acceptance of our cancellation, financial, and payment policies.
You are voluntarily consenting to the rendering of care, including treatment and diagnostic procedures, and you understand that you are under the care and supervision of the attending physician(s). You are acknowledging receipt and understanding of the HIPAA Privacy Notice and your rights and responsibilities as a patient.
By submitting this form, you are also affirmatively stating that you understand and agree to the non-discrimination policy of the clinic and that you consent to the assignment of benefits and release of information as outlined in this form.
Please read the following sections carefully and ask any questions you may have before submitting this form.
Accuracy of Information
I certify that the above medical information is correct to my knowledge.
Privacy and Sharing of Information
I authorize the clinic and its associated health professionals to collect my personal and medical information as documented above. In addition, I authorize the clinic and its associated health professionals to communicate with my family doctor and/or referring doctor as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.
Cancellation Policy
Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in the doctor's day that could have been filled by another patient. As such, we require 5 hours notice for any cancellations or changes to your appointment. Thank you so much for your help!
Financial Policy
Our policy is to extend to you the courtesy of assistance in filing your claim for you with your healthcare insurance company. This policy reduces (but does not eliminate) your out-of-pocket expense.
If you do NOT have insurance: All payments are expected at the time of service or by an authorization payment plan. Your personal balance may not exceed $100 at any time or care may be terminated. Our payment plans make care an affordable part of your family budget.
If you have insurance: All deductibles and co-payments are expected at the time of service or by an authorized payment plan. Your co-insurance balance may not exceed $100 or care may be terminated. Our payment plans make care an affordable part of your family budget. You are considered a cash patient until you bring in your completed insurance forms, and qualify and accept your insurance coverage. We do not accept assignment for secondary insurance carriers but will be happy to provide you with a claim form for your secondary carrier.
Informed Consent
I voluntarily consent to the rendering of care, including treatment and performance of diagnostic procedures. I understand that I am under the care and supervision of the attending physician and it is the responsibility of the staff to carry out the instructions of such physician(s). I have been informed about the nature of the treatment, its risks, benefits, and alternatives and had a chance to ask questions.
HIPAA Acknowledgement
I acknowledge that I have received and had an opportunity to read the HIPPA Privacy Notice, and I understand the ways in which my health information may be used and disclosed as well as my rights with respect to this information.
Non-Discrimination Statement
This clinic does not exclude, deny benefits to, or otherwise discriminate against any person on the ground of race, color, national origin, disability, age, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual's income is derived from any public assistance program, or protected genetic information in admission to, participation in, or receipt of the services and benefits under any of its programs and activities.
Patient Rights and Responsibilities
As a patient, you have the right to receive quality care, to privacy, to confidentiality, and to access your medical records. You also have the responsibility to provide accurate and complete information, to follow the treatment plan, to pay for your care, to ask questions when you do not understand, and to be respectful to healthcare personnel.
Patient Consent Form
Consent for Treatment: I voluntarily consent to the rendering of care, including treatment and performance of diagnostic procedures. I understand that I am under the care and supervision of the attending physician and it is the responsibility of the staff to carry out the Instructions of such physician(s).
Assignment of Benefits: I hereby assign payment directly to the physician(s) accepting this assignment of medical benefits applicable and otherwise payable to me but not to exceed the physician’s regular charges. I understand that I am financially responsible for charges not covered by this assignment or for any and all charges that the insurance carrier declines to pay. It is further agreed that any credit or balance resulting from payment of insurance or other sources may be applied to any other accounts owed to said physician by the insured or his/her family.
Release of Information: The physician(s) may disclose all or part of the patient’s record to any person or corporation which is or may be liable under contract to the physician(s) or to the patient or to a family member or employer of the patient for all part of part of the physician’s charges, including, but not limited to; insurance companies, worker’s compensation carriers, welfare funds, or the patient’s employer.
H.M.O. Disclaimer: I certify that I am not presently enrolled In any Health Maintenance Organization (HMO) Subsequent rejection of a claim as a result of this admission, due to current enrollment in an H.M.O. plan will constitute responsibility for payment of claim on my part,
Medicare and Medicaid Patient Certification-Patient’s Certification Authorization to Release Information and Payment Request:
I certify that the Information given by me in applying for payment under Title XVIII and/or Title XI of the Social Security Act, is correct. I authorize any holder of medical or other information about me, to release to the Social Security Administration or its intermediary carriers, any information needed for this or related Medicare or Medicaid claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for physician(s) services. I understand that I am responsible for my health insurance deductibles and coinsurance.
Yes, I agree to give above written consent.
