Dear Insurance Carrier

Welc omeToday’s Date____/_____/______Patient Name______SS Number_____-_____-______Birth date ___/____/_____Age_____ Mailing Address______City ______State ______Zip ______Home Phone______Alt Phone______E-Mail Address______Status: Minor __Single __Married __Divorced __Separated __Widowed___ Spouse Name______Referred By: ______What kind of insurance do you have? ______Who is the subscriber to the insurance? ______Relation: ______What is his/her birthday? _____/______/______*Don’t forget to give us your insurance card so we can make a copy.In an emergency, who should we contact? ______Relation______Phone number______▪ My insurance policy is a contract between my insurance company and me. This office only bills the insurance for my convenience. If my insurance claim has not been paid within 90 days of billing, the balance automatically becomes my responsibility. I am considered a cash patient until this office has verified my insurance. This office does not process to secondary insurances. This office requires a 24 hour notice for canceling or rescheduling appoints. If you fail to give notice you will be charged accordingly. This office requires that all co pays, cash plans, and deductibles be made before any services are rendered. ▪ As per HIPAA guidelines, we cannot disclose any information about you without your permission. By signing this form, you agreeing to allow us to use your name in our monthly newsletter welcoming the new patients for the month. I also agree to allow Tuckerton Chiropractic Chiropractic Center to use my picture and diagnosis for advertising purposes. ▪ I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided. Signature ______Date____/____/_______Adult Patient __Parent or Guardian __SpouseName: Date:Describe your current complaint(s) and how the problem began:How long have you had this condition?How would you describe the pain? □ Sharp □ Soreness □ Throbbing □ Tingling □ Dull □ Stiffness □ Spasm □ Burning □ Ache □ Weakness □ Numbness □ ShootingHow would you rate the intensity of your pain? ( Circle the appropiate number) 1 2 3 4 5 6 7 8 9 10 (no pain) (terrible/unbearable pain)How often is the pain present? □ Constant (81-100%) □ Frequent (51-80%) □ Occasional (26-50%) □ Intermittent (25% or less)Since your problem began is the pain: □ Getting □ Getting worse better □ Staying the sameHow did your problem begin? □ An auto accident □ Gradual □ Other type of accident □ A work accident □ Sudden □ No specific reason Please explain: What makes your problem better? □ Nothing □ Walking □ Standing □ Sitting □ Moving/exercising □ Lying down □ InactivityWhat makes your problem worse? □ Nothing □ Walking □ Standing □ Sitting □ Moving/exercising □ Lying down □ InactivityWere you previously treated for an earlier occurance of this same condition? If yes, by whom?What were the approximate dates, type of treatment and the results?Please describe any serious accidents with approximate dates:Do you exercise? □ No regular exercise □ 1-2 times a week □ 3-4 times a week □ 5-7 times a week □ Cardiovascular □ Stretching □ Weight Machine □ Free Weights □ Sports (type) What is your present stress level? □ No stress □ Minimal stress □ Moderate stress □ Greatly stressedIs your problem affecting your ability to work or do other routine daily activities? □ No effect □ Have some limited physical restrictions, but can function □ Cannot work □ Need some assistance with daily activities □ Cannot function without assitance □ DisabledDo you have or have you ever had any of the following disease or conditions? □ Seizures/ □ Heart Problems epilepsy □ Arthritis □ High/Low Blood Pressure □ Artificial Bones □ Breathing or Sinus Problems □ Asthma □ Glaucoma □ Immune Diseases □ Stroke □ Ulcers/ Colitis □ Shingles □ Severe Headaches □ Anemia □ HIV/AIDS □ Cancer ( Type:_____ □ Fainting ___ ) □ Alcohol/Drug Abuse □ Psychiatric problemsAre you currently taking any medications ? □ Heart meds □ Pain Killers (including Aspirin) □ Muscle relaxers □ Anti-depressants □ Blood thinners □ Insulin □ Vitamins □ Others Are you allergic to any medications? Y or N If yes, please list:Please list any surgical procedures you have had with approximate dates:Tobacco use: □ Past □ Present □ Occasional □ Moderate □ Heavy Alcohol use: □ Past □ Present □ Occasional □ Moderate □ Heavy Caffeine Use: (Coffee, tea, soft drinks) □ Past □ Present □ Occasional □ Moderate □ Heavy For Women only, are you: □ Pregnant (if yes, how far along are you?) □ NursingPlease shade in the figures below where you have pain, or other symptoms:Signed ______Date ____/____/_____Date: ______Dear Insurance Carrier:I, ______, am currently receiving chiropractic care at ______. Please know that this care is not related to any auto accident, workers’ compensation injury or any other type of injury, which would render a third party liable for these bills.I trust this statement will clarify this matter and there should be no delay in processing any claims submitted to you by this chiropractic office. If you have any questions, do not hesitate to contact me personally.______Print Name______Signature DateRevised 10/25/08 – CB&C UseThis form has been created by and is the sole property of CB&C, Inc. (973)827-3544Date: ______Dear Insurance Carrier, I understand you may be holding up payment of my claims because you are waiting to update your records regarding my status and my coverage. The following is my updated information:Name of patient ______SS# ______DOB ______Insured Name______Policy ID#______Relation to Insured______PLEASE SELECT FROM SECTIONS BELOW & CHECK ONLY ONE STATEMENT THAT APPLIES TO YOUR INSURANCE COVERAGE – YOU MUST SIGN THAT SECTION:Self:_____ I am the patient AND the insured AND I have no other insurance coverage______Signature DateSpouse / Partner:_____ I am the patient, BUT the insured is my spouse/partner ______. I am not employed and therefore have no other insurance coverage of my own._____ I am the patient, BUT the insured is my spouse/partner ______. I am employed at ______but have no coverage through that employer._____ I am the patient & have my own coverage - the following is my coverage information:Primary Ins ______Insured Name: ______Insured DOB: ______Secondary Ins ______Insured Name: ______Insured DOB:____________Signature DateDependent Child (out of high school and older): (covered under parent’s policy)_____ I am a Full Time student & have 1 policy. Attached is my current school schedule.Primary Ins ______Insured Name: ______Insured DOB: ______I am a Full Time student & have 2 polices. Attached is my current school schedule.Primary Ins ______Insured Name: ______Insured DOB: ______Secondary Ins ______Insured Name: ______Insured DOB:____________Signature DateDependent Child Under (high school and under): (covered under parent’s policy)_____ I am a minor dependent and only covered under one policy :Primary Ins ______Insured Name: ______Insured DOB: ___________ I am a minor dependent and covered under two policies :Primary Ins ______Insured Name: ______Insured DOB: ______Secondary Ins ______Insured Name: ______Insured DOB:____________Parent or Guardian Signature DateRevised 5/12/13This form was created by and is the sole property of CB&C, Inc. (973)827-3544ASSIGNMENT OF BENEFITS / ERISA AUTHORIZATION FORMRobert E. Lee, DC Financial ResponsibilityI have requested professional services from Robert E. Lee, DC on behalf of myself and/or my dependents, and understand that by making this request; I am responsible for all charges incurred during the course of said services. I understand that all fees for said services are due and payable on the date services are rendered and agree to pay all such charges incurred in full immediately upon presentation of the appropriate statement unless other arrangements have been made in advance.Assignment of Insurance Benefits I hereby assign all applicable health insurance benefits to which I and/or my dependents are entitled to Robert E. Lee, DC. I certify that the health insurance information that I provided to Robert E. Lee, DC is accurate as of the date set forth below and that I am responsible for keeping it updated.I hereby authorize Robert E. Lee, DC / CB&C to submit claims, on my and/or my dependent’s behalf, to the benefit plan (or its administrator) listed on the current insurance card I provided to Robert E. Lee, DC / CB&C, in good faith. I also hereby instruct my benefit plan (or its administrator) to pay Robert E. Lee, DC directly for services rendered to me or my dependents. To the extent that my current policy prohibits direct payment to Robert E. Lee, DC, I hereby instruct and direct my benefit plan (or its administrator) to provide documentation stating such non-assignment to myself and Robert E. Lee, DC upon request. Upon proof of such non-assignment, I instruct my benefit plan (or its administrator) to make out the check to me and mail it directly to Robert E. Lee, DC.I am fully aware that having health insurance does not absolve me of my responsibility to ensure that my bills for professional services from Robert E. Lee, DC are paid in full. I also understand that I am responsible for all amounts not covered by my health insurance, including co-payments, co-insurance, and deductibles.Authorization to Release InformationI hereby authorize Robert E. Lee, DC / CB&C to: (1) release any information necessary to my health benefit plan (or its administrator) regarding my illness and treatments; (2) process insurance claims generated in the course of examination or treatment; and (3) allow a photocopy of my signature to be used to process insurance claims. This order will remain in effect until revoked by me in writing.ERISA AuthorizationI hereby designate, authorize, and convey to Robert E. Lee, DC to the full extent permissible under law and under any applicable insurance policy and/or employee health care benefit plan: (1) the right and ability to act on my behalf in connection with any claim, right, or cause in action that I may have under such insurance policy and/or benefit plan; and (2) the right and ability to act on my behalf to pursue such claim, right, or cause of action in connection with said insurance policy and/or benefit plan (including but not limited to, the right to act on my behalf in respect to a benefit plan governed by the provisions of ERISA as provided in 29 C.F.R. §2560.5031(b)(4) with respect to any healthcare expense incurred as a result of the services I received from Robert E. Lee, DC and, to the extent permissible under the law, to claim on my behalf, such benefits, claims, or reimbursement, and any other applicable remedy, including fines.A photocopy of this Assignment/Authorization shall be as effective and valid as the original.Patient - Print here and sign above DatePolicyholder/Insured Date Tuckerton Chiropractic CenterDr. Robert E. Lee1 Leifried LaneTuckerton, NJ 08087(609) 209-0440 Cancellation Policy I am aware that all appointments need 24 hours notice of cancellation. I am aware that if I fail to give 24 hours notice of cancellation for a Chiropractic visit I will be charged $25 for that visit, not to be charged to my insurance company. I am aware that if I fail to give 24 hours notice of cancellation for a massage, I will be charged the full cost of the massage.Patient Signature: ______Patient Name: ______Date: ______

Dear Insurance Carrier

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