New Patient Intake

New Patient Intake

Please complete this form prior at least 24 hours prior to your appointment. Feel free to call if you have problems with this form. Our office number is 919-322-4383. We look forward to seeing you soon!
Name*

First NameLast Name
Preferred name (if different than legal name)
Patient's Date of Birth*

MonthDayYear
What sex were you assigned at birth?*

FemaleMalePrefer not to say
Medicare Advance Beneficiary Notice of Non-coverage (ABN)

Please note: If Medicare doesn't pay for services recieved, you may have to pay. Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need.

We expect Medicare may not pay for the services listed below.

99203/99204 - Initial Exam - $175

99213/99214 - Re Exam - $20 with Adjustment

98940/98941 - Spinal Adjustment - $65

98943 - Extremity Adjustment - $55

97110 - Therapeutic Exercises - $22

97140 - Manual Therapy - $22/unit

97810/97811 - Acupuncture - $95

72082 - Full Spine X-Rays - $75

S8990 - Maintenance/Wellness Collective Adjustment - $55

WHAT YOU NEED TO DO NOW -
- Read this notice, so you can make an informed decision about your care.
- Ask us any questions that you may have after reading this form.
- Choose an option below about whether to receive the above listed services.
  Note - If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.
This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048). Signing below means that you have received and understand this notice. You may also receive a copy.

CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call: 1-800-MEDICARE or email: AltFormatRequest@cms.hhs.gov
Options: Check only one box. We cannot choose a box for you.*

Option 1: I want the services listed above. You may be asked to pay now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn't pay, I'm responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.Option 2: I want the services listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.Option 3: I don't want the services listed about. I understand with this choice I am not responsible for payment, and cannot appeal to see if Medicare would pay.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*

Area CodePhone Number
How did you hear about our office?*

Family MemberFriendDoctor ReferralHealth InsuranceGoogle/Internet Search
Where online did you see us?*

Social MediaGoogle Search
Referring Friend/Family Member's Name*
Referring Doctor's Name or Office Name*
Referring Doctor's Office Phone Number

Area CodePhone Number
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Do you have a Primary Care Physician?*

yesno
Primary Care Doctor's Name or Office Name
Physician's Phone Number

Area CodePhone Number
Health Insurance Provider*

Aetna (includes State Health Plan)Blue Cross Blue Shield (includes Anthem)CignaVeteran's AffairsMedicareUnited HealthcareSelf pay / no health insuranceOther
Health Insurance Policy Information

We will verify your health insurance benefits and provide you with your financial responsibility at the start of care. Insurance benefits quoted to us are not a guarantee of payment or coverage. You are responsible for any amount shown on your EOB (explanation of benefits) once your claims have been filed. ******Please note: we are in network with Aetna, BCBS, Cigna, VA, and Medicare. Cash discounts and payment plans available if we are not in network with your insurance.
I understand that health insurance benefits quoted is not a guarantee of payment and I can reference my Explanation of Benefits (EOB) from my insurance company to determine final amounts. Please initial here:*
Subscriber ID / Member ID*
This is generally listed on the front of your insurance ID card and may be alpha numeric. Please include all characters listed including any listed suffix (01,02,03, etc)
Relationship to the Insured*

I am the policy holderMy spouse is the policy holderI am a dependent of the policy holder
Policy Holder's Name*

First NameLast Name
Policy Holder's Date of Birth*

MonthDayYear
Date
Current Condition Information

Please use the following fields to describe what brings you into our office.
What is your primary reason for coming in?*

I am seeking pain reliefI am not currently experiencing pain, I am seeking services to improve overall health and nervous system function
Are you pregnant?*

yesnoit's possible
What is your estimated due date?*

MonthDayYear
Date
Please select the health concern that best describes what you are experiencing.*

Neck PainLow Back PainHeadachesUpper Extremity PainLower Extremity PainOther
Do any of these other conditions apply?*

CancerRecent accident/fall/traumaHIV/spinal infection/major organ transplantProlonged use of steroidsSpinal InfectionOsteoporosisFractureLumbar SurgerySpondylopathyNeoplasmNone of the Above
How long have you had this complaint*

Less than one week2-4 weeksOver a monthOver a yearOther
When was the first time you noticed this complaint?

This is the first timeThis has happened beforeIt's been on and off for years
In the last two weeks how is your complaint changing?*

Geting betterGetting worseStaying the same
What have you tried in the past to alleviate your symptoms?*

chiropracticmassage therapyphysical therapyheat / iceibuprofenprescription pain management / muscle relaxersOther
Do you have a history of any of the following conditions?*

StrokeHeart AttackNone of the above
You will be evaluated for Chiropractic care on your initial visit. Please indicate any other services of interest.*

Massage TherapyLaser TherapySpinal DecompressionAcupuncture/Dry NeedlingInfrared SaunaFunctional MedicineHydrotherapy (nonimmersive, non contact)
Please list any other providers you have seen for this condition

My Primary Care PhysicianOrthopedic PhysicianMassage TherapistPhysical TherapistAnother Chiropractor
When did this provider last treat your current condition? (estimate the date to the best of your ability)*
Is your pain a result of any of the following?*

motor vehicle accidentsports injuryI have not had any accidentsOther
Please select all that apply*

My occupation is sedentaryI work 7+ hour daysMy occupation is not sedentaryOther
Date of Accident*

MonthDayYear
Date
Which seat did you occupy in the vehicle at the time of impact?*

front driver sidefront passenger siderear or back seatOther
Were you wearing a seatbelt?*

yesno
Did the airbag deploy?*

yesno
Which statement describes the accident best?*

I was completely surprised and did not see it comingI saw it coming
Pleas describe, to the best of your knowledge, what happened during the accident*
Please select the most appropriate statement below regarding your medical treatment after the accident*

I was treated immediately afterwards at an Urgent Care or Emergency DepartmentI was treated within 72 hours at an Urgent Care or Emergency Department, but not immediately after the accidentI did not seek medical treatment within 72 hours of the accident
What treatment have you received since the accident?*

Chiropractic CarePhysical TherapyPrimary Care Physician VisitNone
Do you have an open claim regarding the accident?*

yesno
Do you intend to open a claim or get an attorney regarding this accident?*

yesno
Auto Insurance Information
Please select the best option*

I am the responsible party in the accidentThe other party was the responsible party in the accidentSomeone else was responsible - if you were not driving but were in the at fault vehicle
Your Auto Insurance Carrier*
Your Auto Insurance Policy Number*
Your Auto Claim Number
Your Claim Adjuster's Name

First NameLast Name
Your Claim Adjuster's Phone Number

Area CodePhone Number
Do you have an attorney handling this claim?*

yesno
Attorney's Name*

First NameLast Name
Attorney's Phone Number*

Area CodePhone Number
***PLEASE NOTE*** If you elect to pursue auto liability insurance to cover the cost of your care, you may not be able to retroactively bill your health insurance due to timely filing guidelines.

Assignment of Payment
My attorney and/or insurance carrier are hereby requested and authorized to pay direct to Gard Wellness Center any monies due on account, the same to be deducted from any settlement made on my behalf. Further, I agree to pay Gard Wellness Center the difference, if any between the total amount of charges on my account and the amount paid by the attorney and/or insurance carrier. It is further understood that I, the undersigned agree to pay Gard Wellness Center the full amount of charges on my account should my condition be such that it is not covered by my policy or if for any reason the insurance carrier refuses to pay my claim.
Full Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
By signing below, you acknowledge your understanding of responsibility of payment. The patient will be responsible for any balance not covered by auto or health insurance. *Please sign your full name**

Clear

The quality of my pain listed above is characterized as*

burningstabbingdull/achestiffpins and needles / tinglingOther
Does this pain radiate/shoot to any of the following areas (please indicate which side)?*

rightleftshoulder / arm / hands / fingersbuttocks / legankle / footnot applicable
This pain is*

constanton and off

Please indicate how your condition impacts the following activities of daily living - an answer for each is required. *

	painful	some pain	not affected
bending
lifting
stairs
sitting
standing
walking
exercising
housework
kneeling

Please list any imaging you have had in the last three months (please bring recent images with you to your first appointment if possible)

Spinal X-RaySpinal MRI
I hereby authorize the aforementioned office and any of its appointed assistants to disclose the following information from the patient's healthcare record.
This information is to be disclosed to:

Agency/Business Name: Gard Wellness Center
Phone #: 919-322-4383
Fax #: 919-585-5568
Provider's Name:
Provider's Phone Number

Area CodePhone Number
Current Supplements/Over the Counter Medications - list none if you aren't currently taking any*
Prescription Medications - list none if you aren't currently taking any*
Do you use tobacco products?*

NoYesOccasionally
How often to you consume alcoholic drinks?*

rarely / never1-3 drinks per week3-5 drinks per weekover 6 drinks per week
Health History

Please indicate any past or present conditions listed below. Check all that apply.
General:*

recent unintentional weight lossfeverextreme fatiguenone in this category
Musculoskeletal*

Broken BonesPrevious SurgeryNone in this category
Please list any broken bones or surgeries below and their date of occurance: *
Neurological*

numbness or tingling sensationsstrokeloss of feelingdizziness or lightheadedfrequent or recurrent headacheshead injury / concussionnone in this category
Gastrointestinal*

loss of appetitebloody stoolconstipationdiarrheanausea or vomittingregular abdominal pain / bloatingnone in this category
Cardiovascular / heart*

chest painrapid or heartbeat changesblood pressure regulation problemshigh cholesterolswelling of ankles and feethistory of heart attackdiagnosed cardiovascular diseasenone in this category
Respiratory*

difficulty breathingpersistent coughasthmacoughing bloodnone in this category
Eyes / vision*

blurred or double visioneye disease or injurywear glasses / contactsnone in this category
Genitourinary*

kidney stonesburning / painful urinationfrequent urinationurinary leakage / bed wettingblood in urinenone in this category
Endocrine, hematologic, lymphatic*

thyroid problemsdiabetescold hands / feetimmune system disordernone in this category
Skin and breasts*

rash / itchingnon-healing soresbreast painbreast lumpnone in this section
Do you or your family have a history of any of the following? (check all that apply)*

cancerheart diseasestrokenone of the above
Associated Fees:

The doctor may decide it is medically necessary to include digital xray imaging of one or more areas of your spine or extremity, regardless of previous imaging. Women who think they may be pregnant will not receive xrays. Please let your doctor know if there is a chance you may be pregnant. Xrays are generally covered by your insurance subject to copay/coinsurance/deductible. Our office performs routine digital xrays yearly to optimize your care and make sure nothing is ever overlooked. These updated images are not covered by insurance and pricing will be discussed at the time of scheduling in the future.

Informed Consent:

As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation/ massage therapy / acupuncture / cold laser. These complications include but are not limited to: muscle strain, tenderness, fractures, soft tissue injuries, cervical radiculitis and costovertebral strains. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to complications including stroke. Some patients will feel some stiffness and soreness following the first few days of treatment. We use comprehensive examinations to screen for contraindications to care; however, if you have a condition that would otherwise not come to our attention, it is your responsibility to inform us.
HIPAA Privacy Practices Below
I have reviewed the HIPAA Privacy Practices for Gard Wellness Center (above) - Please sign in the box below:*

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New Patient Intake

Health Insurance Policy Information

Current Condition Information

Auto Insurance Information

Health History