Arkansas Physical Medicine and Rehabilitation
636 West Broadway
North LIttle Rock, AR 72114
501-374-1153

Patient Intake Form

Welcome to our online Patient Intake Form. The information you fill in will be sent directly to our office, speed up your office visit, and will help us to better serve your healthcare needs. Please take a moment to completely fill out this form, and upon completion of all form categories click the [Submit] button at the bottom of this form.

For your protection and security; Navigating away from this form before clicking the [Submit] button will dismiss all completed form fields. Successful submission will redirect you to a confirmation page.

Patient Information


Personal Information
Contact Information
Feet Inches
   
 

(We will NOT share your email with any third party. We will only use your email to contact you in relation to your care with our practice.)

   

Draw Your Symptoms


Click on a crayon and draw on the body above to indicate your symptoms
Ache / Dull Sharp / Stabbing Numb / Tingling Pins & Needles Burning Throbbing Cramping Radiating Other Pains eraser eraser clear

How did you find out about our office?


Did you hear about our office from an advertisement?

If Yes, Where:

Did you hear about our office from a phone or professional directory?

If Yes, Where:

Employment Information


Current Symptoms


If Yes, Explain:

If yes:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Where?




Insurance & Payment for Care


Primary Insurance
Secondary Insurance

If an auto accident, please provide:

Chiropractic Experience

Please select all that apply.

Other:

If yes…

What was the reason for those visits?

Doctor's Name:

Approximate date of last visit:

Reason for this Visit

If you're only here for chiropractic wellness services please skip this section.

Does this concern interfere with:





Results:

For Women Only

COMPLETE THIS SECTION ONLY IF YOU ARE (OR THE PATIENT IS) A WOMAN OVER 16 YEARS OF AGE.

Goals for Your Care

People see a chiropractor for a variety of reasons. Some go for relief of pain, some to correct the cause of pain and others for correction of whatever is malfunctioning in their body. Your doctor will weigh your needs and desires when recommending your care program. Please check the type of care desired so that we may be guided by your wishes whenever possible.




Worker's Compensation







Describe the accident?

Do you lift from?

Do you have to reach?
Is your work area cluttered?
Do you push or pull?
Do you pick up or lift?

Do you lift in and out of a machine?
Type of Floor:

Type of ventilation:

Type of lighting:

Is your work area:

Do you have any other jobs?
Has outside help been hired?
Do you use a cart?



Auto Accident










Visited a Hospital or Doctor?






Were you rendered unconscious?
Traffic violation issued?
Retained an attorney?

In relation to the base of your skull, where was the headrest?

Impact to your vehicle came from?

The direction you were heading?
The direction they were heading?

The direction you were facing?
What did your vehicle impact?

Strike anything in the vehicle?

Describe the accident?

How did you feel right after?

Names of all persons in this accident:

Electronic Health Record (EHR) Information


Preferred Language: Ethnicity:
Race:
Smoking Status: Smoking Start Date:
Type of Tobacco:
Have you tried to quit? How much tobacco do you use?
How long have you used tobacco?
Current Medications And Dosage:
Medication Name Dosage
Medication Allergies:
Medication Name Reaction Date Discovered

Authorization

HEALTH CARE PRIVACY NOTICE--INFORMED CONSENT--ASSIGNMENT OF BENEFITS--AUTHORIZATION & LIENThis office is committed to providing patients with quality health care services delivered with dignity and concern. Fulfilling this commitment requires the efforts of the doctors, therapists, staff and patient working together as a team to obtain the maximum results. Patient satisfaction is a vital interest to our staff. This Facility is required by law to abide by the terms of this Health Care Privacy Notice as well as other applicable federal and state laws governing privacy practices in health care. Our Facility may change and/or modify the terms of this Notice at any time without additional notice to you except to publicly post in our Facility and/or make available to patients any updated notices. Photocopy of this Notice is available to you upon request. The term Facility refers to this office or clinic. The term Provider refers to doctors and/or licensed professionals of this Facility. Our Facility & staff are committed to maintaining the privacy of your protected health information (PHI). PHI is information about you, including demographic information that may identify you and that may be related to your present, future and past physical or mental health or condition and the care and treatment you receive from our practice. This Notice describes how medical information about you may be used and disclosed and how you can obtain access to this information. Please read this Notice and direct questions, misunderstandings or concern to the Compliance Officer of this Facility. Our Facility may use & disclose your PHI for health care delivery purposes. Your PHI may be used and/or disclosed without your written authorization by the doctors and staff of this Facility for the purposes of your care and treatment, to your primary and specialty care providers; paying your health care bills; and to support the operations of this practice. Your doctor and the staff will take all reasonable measures to maintain the confidentiality of your PHI. The Privacy Rule allows you the right to review and receive copies of your health care records as it relates to your health care. The request must in writing, allowing your provider 30 days to respond. Your provider may deny your request if it will cause harm to you or to another person. Your provider may charge a copy fee, which will be in compliance with State law. Your provider will comply with any reasonable request to have confidential communication by alternative means or at an alternative location if not doing so endangers you. You may request to have an amendment placed in your record if you disagree with anything in your record. This does not mean that anything will be removed or changed and the provider has the right to respond with a rebuttal statement if he/she feels it is necessary. You may revoke authorization, in writing, at any time, except in the event that the provider has acted as indicated in the doctor’s Authorization Notice. You have the right to file a written complaint with our Compliance Officer if you believe that any of your privacy rights have been violated. You can obtain a complaint form from the Compliance Officer and/or the Office of the Civil Rights. All complaints must be filed within 180 days of when you knew or should have known that the violation occurred. The Privacy Law prohibits our Facility from taking any retaliatory actions against anyone who files a complaint. A more detailed, updated & comprehensive Health Care Privacy Notice is available for your review in this Facility. I understand that this Facility, its doctors & staff are accepting my case based on examination findings & believe the outlined treatment should produce change and/or improvement. However as with any diagnostic test, procedure, examination or doctors care a guarantee of improvement or complete recovery cannot be made and it is even possible that no change will occur. I further understand that in the practice of medicine, chiropractic, psychological counseling, massage therapy & physical therapy there are some risks including but not limited to fractures, disk injuries, strokes, dislocations, sprains-strains, drug interactions & reactions and/or other injuries or side effects which cannot be pre-determined. I do not expect the doctor/provider to be able to anticipate and explain all risks and/or complications, and I wish to rely on the doctor/provider to exercise judgment during the course of the procedure(s) which the doctor/provider feels at the time is in my best interest. In addition, because psycho-social, spiritual, and cultural values affect a patient’s response to care, patients are allowed to express and follow spiritual beliefs and cultural practices that do not harm others or interfere with the planned course of treatment. Patients have the right to refuse treatment, but must be aware of the probable consequences of refusing treatment and/or failing to cooperate with the prescribed treatment. Should you refuse and/or fail to comply with prescribed treatment your provider will discuss specific consequences with you. Therefore I give my full consent to the doctor/provider to render treatment on me or the minor for whom I am legally responsible by a health care provider of this Facility.. I, the assignee, being the patient or legal guardian for said minor listed below, do hereby irrevocably authorize, direct, assign and give a full lien to the office named above and listed below, hereinafter referred to as the “Facility” against any & all insurance benefits, proceeds of any settlement, judgment or verdict which may be paid to the undersigned as a result of the injuries or illness for which I have been treated by the Facility. I, the assignee further authorizes any and all insurance company, attorney and any & all third party payer to pay directly to the Facility all sums of money due them for any & all services rendered to me or minor by whom I am responsible for by reason of accident, illness and by any & all reason of any other bills that are due or may become due, and to withhold such sums from any health & accident, workers compensation and or including all insurance or third party benefits. Assignee agrees that this Facility & staff may deliver medical records, consultations, depositions and/or court appearances which must be paid in full in advance and authorizes this Facility to release any information pertinent to said health care to any insurance company, adjuster, attorney or legal service bureau to facilitate collections under the terms of this document. Assignee grants the Facility a full power of attorney to endorse &/or sign my name on any & all checks for payment of any indebtedness owed this office & assignee. INSURANCE BENEFITS – CREDIT POLICIES – PAYMENT TERMS & CONDITIONS As a courtesy, the Facility will obtain a verification of applicable insurance benefits as they are quoted to us but some third party payers misquote benefits, coverage and liability. Our Facility & staff are not responsible for what a third party payer and/or representative may tell us. Any contractual, written, verbal or other obligations or arrangements between you and an attorney, insurance company, liable or third party payer are between you and said person. 1. Our Facility will file initial insurance claims for you. Secondary claim submission and/or additional reports or documents sent for your benefit may result in an additional filing or medical report charges, which you are responsible to pay. Co-pays, deductibles and all non-covered services are due the day the service is rendered. 2. Patients are responsible for charges on all service(s) and/or product(s) which may exceed the maximum allowable and/or when a third party and/or insurance carrier does not reimburse this Facility enough to meet our cost of service. 3. All account balances, including automobile and work injury claims must be paid in full within 90 days of treatment. Patients are fully responsible for all money owed this office and such payment is not contingent on any settlement, claim, judgment, or verdict by which they may eventually recover said fee and it is also regardless of any attorney liens or pending settlement(s). If a third party payer fails to pay said balance in full within the 90-day period, the patient must pay the balance in full. Assignee is fully responsible for all money owed this Facility for any and all treatment, products & services rendered to the patient or minor shown below. 4. A non-discriminatory “Time of Service Discount” is offered to anyone who pays for services the day they are rendered. The “TOS” is only offered on the day the service is rendered. This discount does not apply to orthopedic supports, orthotics, physical therapy equipment rentals or purchases, vitamins, supplements, ointments, acupuncture treatments, weight loss programs, psychological counseling services and massage therapy. 5. A service charge is computed by a ‘periodic rate’ of 1½ % per month – 18% per annum & is added to all balances owed 60+ days. Any balance past due 90 days or more may be submitted to an attorney and/or agency for legal collection for which the undersigned agrees to be 100% responsible for all monthly service charges, interest, costs related to but not limited to all collection related expenses, attorney fees, court & filing fees. Returned checks, debit & credit charges made payable to this Facility for insufficient funds, stop payments or other reasons of non-payment will be assessed a $35.00 charge. 6. Patients are eligible for a maximum $750 personal credit limit when approved. For your convenience we accept most major credit & debit cards. 7. I authorize APMR and or its agents to request information from credit reporting agencies for all purposes it deems necessary in order to collect on my account. 8. I authorize the use of my email address for medical records and medical documentation, appointment reminders, balance inquires or other promotional information from my doctor.9. 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. By my signature below I acknowledge that I have read or have had read to me and have received a photocopy upon my request of this document including the Health Care Privacy Notice, Facility terms & conditions, credit policies and Informed Consent and fully understand and have had all of my questions answered to my satisfaction. A photocopy of this document shall be considered as effective and valid as an original.

Name of the Insured:
(Please Print)
_____________________________________________    
Patient's/Guardian's signature:
_____________________________________________
Date:
__________

Signature


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