Child Chiropractic Care New Patient Form

New Pediatric Patients Start Here!
Follow these steps to complete your child's paperwork in 15-20 minutes:

Step 1: Provide Your Contact Information
Step 2: Tell us the Reason for Your Child's Visit
Step 3: Answer some Health History Questions
Step 4: Read Important Information about Your Privacy (HIPAA)
Step 5: Sign the Consent to Treatment Page

Click the Start button to begin.

Step 1: Provide Your Contact Information
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Phone Number (secondary)
E-mail*
Who referred you to us?
Is this the first time you have visited a chiropractor?

YesNo

Step 2: Tell us the Reason for Your Child's Visit
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Child's Age*
Child's Gender*

MaleFemale
Child's Legal Guardian*

First NameLast Name
What is the reason for this visit?
When did the problem start?
What symptoms have you noticed?
Has your child experienced this before?

YesNo
Have you seen a pediatrician about your concerns?

YesNo
Pediatrician's name:
Did the pediatrician order any labwork or imaging for diagnosis?
If so, what were the results? (Enter n/a if not applicable)
What have you done thus far to help your child? Has it helped?
What, if anything, seems to make the symptoms worse?

Step 4: Read Important Information about your Privacy (HIPAA)

Maimonides Chiropractic is committed to maintaining the privacy of your protected health information (“PHI”), which includes information about your medical condition and the care and treatment you receive from our practice and other health care providers. As a patient of Maimonides Chiropractic, your PHI may be used and disclosed to third parties for purposes of your care, payment for your care, health care operations of the practice, and for other purposes permitted or required by law.

Maimonides Chiropractic may use and/or disclose your PHI for purposes related to your care, payment for your care, and health care operations of the practice. The following are examples of the types of uses and/or disclosures of your PHI that may occur. These examples are not meant to include all possible types of use and/or disclosure.

Care – In order to provide care to you, Maimonides Chiropractic will provide your PHI to those health care professionals directly involved in your care so they may understand your medical condition and needs and provide advice or treatment. For example, your physician may need to know how your condition is responding to the treatment provided by Maimonides Chiropractic.

Payment – In order to get paid for some or all of the health care provided by Maimonides Chiropractic, we may provide your PHI, directly or through a billing service, to appropriate third party payers, pursuant to their billing and payment requirements. For example, we may need to provide your health insurance carrier with information about health care services you received from the Practice so the Practice may be properly reimbursed.

Health Care Operations – In order for Maimonides Chiropractic to operate in accordance with applicable law and insurance requirements and in order that we may provide quality and efficient care, it may be necessary for us to compile, use and/or disclose your PHI. For example, we may use your PHI in order to evaluate the performance of our personnel in providing care to you.

Your name, address, telephone number and your healthcare records may be used to contact you regarding appointment reminders, information about alternatives to your present care or for other health-related information that may be of interest to you. If you are not at home to receive an appointment reminder, a message may be left on your answering machine.

You have the right to inspect or obtain a copy of the information we will use for these purposes. You also have the right to refuse to provide authorization for this office to contact you regarding these matters. If you do not provide us with this authorization, it will NOT affect the care provided to you or the reimbursement avenues associated with your care.

Under federal law, we are also permitted and/or required to use or disclose your health information without your consent or authorization in these circumstances: if we are providing healthcare services to you based on the orders of another healthcare provider; if we provide healthcare services to you in an emergency; if we are required by law to provide care to you and we are unable to obtain your consent after attempting to do so; if there are substantial barriers to communicating with you but in our professional judgment we believe that you intend for us to provide care; if we are ordered by the courts or another appropriate agency. Any use or disclosure of your protected health information other than as outlined above will only be made upon your written authorization.

A complete copy of our HIPAA Notice of Privacy Practices is available on our website at www.MaimonidesChiropractic.com.
Electronic signature*

I understand and agree to the privacy standards of Maimonides Chiropractic.

Step 5: Sign the Consent to Treatment Page

This section contains important information about payments, insurance, scheduling, and cancellations.

Payments and Insurance Assignment

Our office is in-network with Blue Cross-Blue Shield and Carefirst PPO programs and Medicare ONLY. We are out-of-network with all other companies effective September 1, 2014.

If we are in network with your plan, your co-pay, co-insurance, or allowed amount is due at the time of services are rendered as dictated by your policy. We will file claims with your insurance company after each visit and assist you in every way we can.

If we are out-of-network with your insurance company, we ask that you make payment in full at the time of each visit. After your visit, we will be pleased to email you a superbill which contains all the information necessary for you to submit for reimbursement from your insurance company. We cannot guarantee how your insurance company will behave or pay. We will not enter into any disputes with your company because the relationship is between you and your insurance company alone.

If you will not be using insurance at all, please make sure to ask about the Preferred Chiropractic Doctor program (www.youbewell2.com) which offers a cash discount on our services and products. This program has been a favorite of our military families for over a decade but you do not have to be a military family to benefit!
Electronic signature*

I understand and accept the payment and insurance policies at Maimonides Chiropractic.
Cancellations and Rescheduling

When life happens and you must reschedule your appointment, we are happy to help. Please help us help you.

If something comes up, call us within 24 hours of your visit to give us notice so that we may schedule you for the soonest next available appointment. In this way we may offer your time to someone who may really need help.

Missed Appointments

The first time a scheduled appointment is missed without proper notice, you will not be charged. Everyone forgets sometimes.

The second time a scheduled appointment is missed without proper notice, our office will charge the patient 50% of the entire value of the visit missed.

The third time this occurs, our office reserves the right to charge the patient for the value of the entire visit before scheduling future appointments.

After this, our office reserves the right to reconsider our ability to schedule the patient in the future.
Electronic signature*

I understand and accept the cancellation policies at Maimonides Chiropractic.
Informed Consent to Treatment

When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective. It is important that each person understand both the objective and the method used to reach this goal. This will prevent any confusion or disappointment.
Our chiropractic method is to perform specific adjustments of the spine in order to correct vertebral subluxations. An adjustment is a controlled and precise force placed into a subluxated area to restore movement, correct neurological imbalance and promote healing.

What is a vertebral subluxation?

A vertebral subluxation is a misalignment of one or more of the 24 vertebra in the spinal column, occiput, ribs and sacrum, which causes alteration of nerve function and interference to the transmission of mental impulses. This results in a lessening of the body’s innate ability to adapt to the environment around us.

Health here is defined as a state of optimal physical, mental, and social well-being, not merely the absence of disease or infirmity.

In addition to chiropractic adjustments, occasionally we may suggest and use a technique called Total Body Modification (TBM). TBM is an adjunct to the chiropractic techniques used in our office for the restoration and maintenance of the optimum health of our patients. It eliminates road blocks so that the body can heal itself. By using organ reflex points and specific spinal adjustments, it can help enhance cooperation between the various functions of health.

If during the course of a chiropractic spinal evaluation, we encounter unusual findings, we will advise you and recommend you seek the services of a health care provider who specializes in that area.
Electronic signature*

I understand, agree, and consent to be treated at Maimonides Chiropractic.
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