It is Usual and Customary to Pay for Services as Rendered Unless Otherwise Arranged.
HISTORY OF PRESENT ILLNESS
HISTORY OF PRESENT ILLNESS
PAST, FAMILY, AND SOCIAL HISTORY
PAST MEDICAL HISTORY
Have you ever had any of the following? Please select all that apply and use comments to elaborate.
SOCIAL AND OCCUPATIONAL HISTORY
REVIEW OF SYSTEMS
Many of the following conditions respond to chiropractic treatment.
Are you currently experiencing any of these symptoms? (Please select all that apply and use comments to elaborate.)
I have answered these questions to the best of my knowledge and certify them to be true and correct.
FUNCTIONAL RATING INDEX
For use with Neck and/or Back Problems only.
In order to properly assess your condition, we must understand how much your neck and/or back problem have affected your ability to manage everyday activities.
For each item below, please check on which most closely describes your condition right now.
Consent of Professional Services and Release of Information
I herby authorize the doctor and whomever they may designate as the assistants to administer: treatment, physical examination, X-Ray studies, laboratory procedures, chiropractic care or any clinic service he/she deems necessary in my case. I further authorize him/her to disclose all or any part of my (patient’s) record to any person or corporation which is or may be liable under a contract to the clinic or to the patient or to a family member or employer of the patient for all or any of the clinic’s charge, including, and not limited to: hospitals, medical service companies, insurance companies, worker compensation carriers, welfare funds, or the patients employer.
Assignment of Health Benefits
The parties appearing below hereby agree to the following conditions, covenants and terms regarding the assignment of health benefits appearing in the policy that has been presented to this office. I hereafter referred to as “Patient”, understand and voluntarily agree to assign all applicable health provisions pertaining to payments or benefits appearing in my insurance policy in consideration for treatment rendered by Dr. Douglas B. Gauthier or Dr. Anne-Laure Gauthier, referred to as “Doctor”. The patient, the policy holder, requests, orders and directs the insurance company to pay Dr. Douglas B. Gauthier or Dr. Anne-Laure Gauthier directly to his/her office at 6008 NW 9Hwy, Suite A, Parkville, MO 64152 or if my current policy prohibits direct payment to the doctor, I hereby understand that it is my responsibility to direct all payments to the address as follows: 6008 NW 9Hwy, Suite A, Parkville, MO 64152 for the sum due to the Doctor for treatment rendered. The patient gives the doctor exclusive right to secure the funds assigned the patient, including the right of securing counsel to represent the Doctor in the collecting all sums due for treatment rendered. The Doctor and Patient hereby enter into the assignment of benefits freely and voluntarily and evidenced by the signatures appearing below: that Patient and Doctor warrant that they have read this assignment of benefits and that each understand the legal effect of the same, and agree that each shall be bound by the covenant, terms and conditions appearing herein. A photocopy of this Assignment shall be considered as effective and valid as the original.
Clinical summary Report (CCR): I understand that a clinical summary report is created after each visit for the purpose of EHR and is available for my review. At this time, I am asking Gauthier Chiropractic to save these electronically for me and not print them out each visit. I understand, upon request, these reports are available to be printed or emailed to me for review.