Patient Update Form printable pdf download

NAME/ADDRESS OF CLINIC/PROVIDER

PATIENT UPDATE FORM

PART A

Name:

DOB

E-mail address:

Cell Phone

Home Phone

Address:

Purpose of this appointment:

Is this the same problem you were originally under care for?

( ) Yes

( ) No

If no, what is your current health issue?

Other doctors seen for this condition:

What medications or drugs are you taking?

PART B

Occupation:

Employer:

Employer's address:

Work Phone:

Spouse:

Spouse's Employer:

Insurance Carrier _________________________________ Policy # _________________________________

Insurance Carrier Phone # __________________________________________________________________

PART C

AUTHORIZATION AND RELEASE: I authorize payment of insurance benefits directly to the chiropractor or chiropractic office. I

authorize the doctor to release all information necessary to communicate with personal physicians and other healthcare providers and

payors and to secure the payment of benefits. I understand that I am responsible for all costs of care, regardless of insurance coverage.

I also understand that if I suspend or terminate my schedule of care as determined by my treating doctor, any fees for professional

services will be immediately due and payable. I understand that interest is charged on overdue accounts at the annual rate of

(16%).

The patient understands and agrees to allow this office to use their Patient Health Information for the purpose of

treatment, payment, healthcare operations, and coordination of care. We want you to know how your Patient Health

Information is going to be used in this office and your rights concerning those records. If you would like to have a more

detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage

you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent. If there is anyone

you do not want to receive your medical records, please inform our office.

Date Signed:

Signature:

Reviewed by __________________________________________

Patient Update Form

Signature of Reviewer ___________________________________

Patient Update Form