Wellness Center of Waltham
88 Maple St
Waltham, MA 02453
781-891-8388

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.)

   

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:

Personal Health History


Family/Primary Physician

Separate details with "," comma as shown above.



Separate details with "," comma as shown above.

Separate details with "," comma as shown above.

Personal Incident History:


If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

Family Health History


Separate details with "," comma as shown above.

(Example: arthritis, cancer, diabetes, heart disease, kidney disease, high cholesterol, etc.)

For Women Only

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

Health Problems & Concerns:


Please select all that you have had or currently have.

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

I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION (HIPAA)THIS NOTICE DESCRIBES HOW WELLNESS CENTER, CHIROPRACTIC AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Uses and Disclosures Here are some examples of how we might have to use or disclose your health care information:1) Your chiropractor or a staff member may have to disclose your health information including all of your clinical records to another health care provider or a hospital if it is necessary to refer you to them for diagnosis, assessment, or treatment of your health condition. 2) Our insurance and billing staff may have to disclose your examination and treatment records and your billing records to another party, such as an insurance carrier, an HMO, a PPO, or your employer, if they are potentially responsible for the payment of your services. 3) Your chiropractor and members of the staff may need to use your health information, examination and treatment records and your billing records for quality control purposes or for other administrative purposes to efficiently and effectively run our practice. 4) Your chiropractor and members of the practice staff may need to use your name, address, phone number, and your clinical records to contact you to provide appointment reminders, information about treatment alternatives, or other health related information that may be of interest to you. 164.520 (b)(1)(iii) (A). If you are not at home to receive an appointment reminder, a message will be left on your answering machine.You have the right to refuse to give us authorization to contact you to provide appointment reminders, information about treatment alternatives, or other health related information. If you do not give us authorization, it will not affect the treatment we provide to you or the methods we use to obtain reimbursement for your care. You may inspect or copy the information that we use to contact you to provide appointment reminders, information about treatment alternatives, or other health related information at any time. Our Privacy Pledge We have and always will respect your privacy. Other than the uses and disclosures we described above, we will not sell or provide any of your health information to any outside marketing organization.Permitted uses and disclosures without your consent or authorization Under federal law, we are also permitted or required to use or disclose your health information without your consent or authorization in these following circumstances:1) We are permitted to use or disclose your health information if we are providing health care services to you based on the orders of another health care provider.2) We are permitted to use or disclose your health information if we provide health care services to you as an inmate.3) We are permitted to use or disclose your health information if we provide health care services to you in an emergency.4) We are permitted to use or disclose your health information if we are required by law to treat you and we are unable to obtain your consent after attempting to do so.5) We are permitted to use or disclose your health information if there are substantial barriers to communicating with you, but in our professional judgment we believe that you intend for us to provide care.Other than the circumstances described in the preceding five examples and under the Uses and Disclosures section above, any other use or disclosure of your health information will only be made with your written authorization.Your right to revoke your authorization You may revoke your authorization to us at any time; however, your revocation must be in writing. There are two circumstances under which we will not be able to honor your revocation request:1) If we have already released your health information before we receive your request to revoke your authorization.164.508(b)(5)(i)2) If you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they decide to contest any of your claims. If you wish to revoke your authorization please write to us at:Mrs. Terri A. Mulhern - See letter head above for contact information Your right to limit uses or disclosures If there are health care providers, hospitals, employers, insurers or other individuals or organizations to whom you do not want us to disclose your health information, please let us know, in writing, what individuals or organizations to whom you do not want us to disclose your health care information. We are not required to agree to your restrictions. However, if we agree with your restrictions, the restriction is binding on us. If we do not agree to your restrictions, you may drop your request or you are free to seek care from another health care provider.Your right to receive confidential communication regarding your health information We normally provide information about your health to you in person at the time you receive chiropractic services from us. We may also mail you information regarding your health or about the status of your account. We will do our best to accommodate any reasonable request if you would like to receive information about your health or the services that we provide at a place other than your home or, if you would like the information in a different form. To help us respond to your needs, please make any request in writing.Your right to inspect and copy your health information You have the right to inspect and/or copy your health information for seven years from the date that the record was created or as long as the information remains in our files. We require your request to inspect and/or copy your health information to be in writing. Your right to amend your health information You have the right to request that we amend your health information for seven years from the date that the record was created or as long as the information remains in our files. We require your request to amend your records to be in writing and for you to give us a reason to support the change you are requesting us to make. Your right to receive an accounting of the disclosures we have made of your records You have the right to request that we give you an accounting of the disclosures we have made of your health information for the last six years before the date of your request. The accounting will include all disclosures except those disclosures:- required for your treatment, to obtain payment for your services, or to run our practice.- made to you.- necessary to maintain a directory of the individuals in our facility- to individuals involved with your care.- for national security or intelligence purposes.- made to correctional officers or law enforcement officers.- that were made prior to the effective date of the HIPAA privacy law.We will provide the first accounting within any 12-month period without charge. There is a fee for any additional requests during the next 12 months. When you make your request we will tell you the amount of the fee and you will have the opportunity to withdraw or modify your request.Your right to obtain a paper copy of this noticeIf you have agreed to receive privacy notices by e-mail, you may request a paper copy of this notice at any time. Our duties We are required by law to maintain the privacy of your health information. We are also required to provide you with this notice of our legal duties and our privacy practices with respect to your health information. We must abide by the terms of this notice while it is in effect. However, we reserve the right to change the terms of our privacy notices. If we make a change to the terms of our privacy agreement we will notify you in writing when you come in for treatment or by mail. If we make a change in our privacy terms the change will apply for all of your health information in our files.Re-disclosure Information that we use or disclose may be subject to re-disclosure by the person to whom we provide the information and may no longer be protected by the federal privacy rules.Your right to complain You may complain to us or to the Secretary for Health and Human Services if you feel that we have violated your privacy rights. We respect your right to file a complaint and will not take any action against you if you file a complaint. While you may make an oral complaint at any time, written comments should be addressed to: The above listed letter head information.To Contact UsIf you would like further information about our privacy policies and practices please contact our office at the above address. This notice is effective as of April 14, 2003 or Date you signed the acknowledgement that you have received this notice. This notice will expire seven years after the date upon which the record was created. Privacy Notice Acknowledgement: WE ARE VERY CONCERNED WITH PROTECTING YOUR PRIVACY, ESPECIALLY IN MATTERS THAT CONCERN YOUR PERSONAL HEALTH INFORMATION. IN ACCORDANCE WITH THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA), WE ARE REQUIRED TO SUPPLY YOU WITH A COPY OF OUR PRIVACY POLICIES AND PROCEDURES. WE ENCOURAGE YOU TO READ THIS DOCUMENT CAREFULLY, FOR IT OUTLINES THE USE AND LIMITATIONS OF THE DISCLOSURE OF YOUR HEALTH INFORMATION AND YOUR RIGHTS AS A PATIENT. IF YOU EVER HAVE ANY QUESTIONS OR CONCERNS REGARDING THE USE OR DISSEMINATION OF YOUR PERSONAL HEALTH INFORMATION, WE WOULD BE HAPPY TO ADDRESS THEM.I ACKNOWLEDGE THAT I MAY OBTAIN A COPY OF METRO-West Neurological and Musculoskeletal Associates Management Corporation NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION.Rescheduling Fee Policy It is the mission of this office to help as many people as possible become healthy and stay healthy. We are more able to reach our goal when all our patients keep their scheduled appointments. With this in mind, we are introducing a $25.00 rescheduling fee for those patients that don’t show up for their regularly scheduled appointments as well as those patients that cancel/reschedule with less than 24 hours notice.I have read and understand that I am responsible for this fee.Fee Schedule Consultation $70.00Spinal Adjustments / Manipulations $70. / $80.00 Extremity Adjustments $50.00 – $80.00 Kinesiological Exam $50.00 – $100.00Physical, Neurological, Orthopedic Exams Comprehensive $225.00Initial / Extensive $225.00Progress $175.00X-ray Interpretation (Per Film) and / or Consultation $50.00Five Film Series / Seven Film Series $225.00 / $325.00Interpretation / Consult on Films / Report of Findings $100.00 – $200.00 Physiotherapy (per unit and or per region) Home Ice Packs with Biofreeze $30.00 - $55.00Ultrasound, Interferential, Russian Stimulation, E. Stim., Mechanical Traction, Diathermy, Vibratory Massage (G5), Muscle Stimulation (Faradic or Galvanic), Hot & Cold Packs $25.00 – $30.00Muscle Massage Rebalancing (/ 10 min.) / Myofascial Release / Rehab Care $60.00 – $120.00Strapping and Taping (per Area) / Synergy Kits$ $50.00 / $100.00Therapeutic Exercises & / or Neuromuscular Reeducation $70.00Orthopedic Supports and Supplements & Nutrition / Educational Materials VariableBlood or Urine Analysis / Interpretation of Laboratory Findings VariableMiscellaneous Rescheduling Fee or Missed / Broken Appointments (without 24 hrs. notice) $25.00Checks returned for insufficient funds (reprocessing fee) [or unwarranted dispute charges] $50.00Photo Copy Fee of Records (per file) $50.00 – $100.00Narrative Report Fee, Indep. Chiropractic / Med. Exam Rebuttals / Dr. Attending Exam/ etc. $300.00 – $1,000.00 Outstanding Balances @ 1.5% monthly or 18% annually – Fees may change without notice!NOTE: There may be other supplies, etc. that may not be listed due to space limitation. If you have any questions or concerns, please ask any of our staff or the doctor during care. I have read and understand that I am responsible for payment of all deductibles and co-payments related to my care. I understand that if I have a balance for medical services not paid, I will make a minimum payment of $50.00 each month or 25% of the outstanding balance whichever is greater. If my balance is not paid in a timely and monthly fashion, I promise to pay any and all collection, court, and attorney fees in the collection of my account. I further understand that if my treatment is associated with a personal injury or accident claim, all medical bills will be paid at 100% of the above fee schedule regardless of the outcome of my case. I understand that if a check, credit card or debit is returned for insufficient funds, I will be charged a $50.00 service charge. I have read and fully understand the above financial terms and prices. A signed photocopy of this document shall be considered as effective and valid as the original. Authorization to Realease Medical Records I hereby authorize Chiropractic Offices of Waltham to release information concerning my diagnosis and treatment to my insurance company and/or attorney (if applicable) for the purpose of processing claims for benefits for this visit or related visits. I am not giving permission for any disclosure of this information other than as specified above. A signed photocopy of this document shall be considered effective and valid as the original. Health Benefit Affidavit Information In accordance with Chapter 273 of the Acts of 1988, we are now required to obtain information regarding other health benefits (HMO, Medicare, commercial health insurance, etc.) available to you before your claim can be processed for personal injury protection benefits (PIP). The Attached page is where you must enter all health insurance information. YOU CAN NOT RECEIVE TREATMENT AT OUR CHIROPRACTIC OFFICE IF THIS AFFIDAVIT IS NOT FILLED OUT PROPERLY AND SIGNED. Any medical expenses in excess of $2000.00 will not be paid under PIP if those expenses will be compensated, paid or indemnified by an outside insurance carrier (HMO, Medicare, commercial health insurance, etc.) Bills submitted to the PIP carrier over the $2000.00 limit, must be accompanied by a statement from your health carrier as to their reason for non-payment. If you have health insurance benefits available to you (it is imperative that you notify your health insurer of your injuries) please complete SECTION ONE. If you have more than one health insurer, please fill in section two also.(DO NOT WRITE YOUR AUTOMOBILE OR WORKERS COMP INSURANCE INFORMATION IN SECTION ONE OR TWO). IMPORTANT! - IN ALL SITUATIONS THE PATIENT IS ULTIMATELY RESPONSIBLE FOR PAYMENT OF THE BILLS FOR TREATMENT. IF, FOR WHATEVER REASON YOUR BILLS ARE NOT PAID BY AN INSURANCE COMPANY, YOU ARE (OR YOUR PARENT IS) LIABLE FOR PAYMENT FOR ALL TREATMENT. WE DO NOT COMPROMISE YOUR TREATMENT AND WE WILL NOT COMPROMISE OUR BILLS.If you don't understand the information presented, ask to have it explained to you before signing it. I, the patient registering for treatment at Wellness Center of Waltham have read this page and understand it fully.

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

Signature


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