CHARLOTTE-Salama-Chiropractic-New-Patient-INTAKE-WELCOME-Form-2-27-2019

New Patient Welcome Form

Salama Chiropractic Center

APPOINTMENT INFORMATION

Which Salama Chiropractic Office Is Your Appointment Scheduled At?

Greensboro - 3410 West Wendover Aveue, Suite A Greensboro - 2608-A Lawndale Drive Oak Ridge - 1692 NC Highway 68, Suite E Winston-Salem - 1515 Hanes Mall Boulevard Charlotte - 2200 Randolph Road

Appointment Date

Appointment Time

PATIENT INFORMATION

Date

Patient Full Name (First, Middle & Last Names)

Address

City

State

Zip

Email

Sex

Male Female

Age

Date Of Birth

Social Security Number

Relationship Status

Spouse’s Name

Spouse's Date Of Birth:

Spouse’s Employer

Occupation

Patient Employer / School

Employer / School Address

Home Phone

Cell Phone

Work Phone

Best Time & Place To Reach You

How Did You Hear About Our Office?

IN CASE OF EMERGENCY CONTACT

Name

Emergency Contact’s Phone Number

ACCIDENT INFORMATION

Is Condition Due To An Accident? (If no, please skip to "Health Insurance" section.)

Yes No

Date

Type Of Accident

If “Other", please describe the type of accident

To Whom Have You Made A Report Of Your Accident?

If “Other”, whom?

Attorney’s Name (If applicable)

HEALTH INSURANCE INFORMATION

Health Insurance Name

Health Insurance ID Number

Group Number

Who Is The Primary Insured?

What Is The Date Of Birth Of The Primary Insured?

Relationship To Patient

Is The Patient Covered By Additional Insurance?

Yes No

If “Yes”, then please fill in the the form fields below.

2nd Insurance Company Name

Subscriber’s Name

Date of Birth

Relationship To Patient

Group Number

FINANCIAL RESPONSIBILITY

I understand that if presented, my insurance will be billed and that I am at all times financially responsible to Salama Chiropractic Center for all "patient responsible" charges as confirmed on the explanation of benefits received by us from your insurance company as listed on their explanation of benefits once claim has been processed and finalized. It is my responsibility to notify Salama Chiropractic Center of any changes in my health care coverage. In some cases exact insurance benefits can not be determined until the insurance company receives the claim. I understand that by signing this form that I am accepting financial responsibility for my responsible portion as listed on my explanation of benefits once processed by the insurance company and as explained above for all payment for medical services and/or supplies received. If no insurance is presented, I agree to pay in full for all services rendered each visit. I understand a Good Faith Estimate will be provided prior to any services being performed.

ASSIGNMENT OF BENEFITS

I authorize direct remittance of payment of all insurance benefits, including Medicare, if I am a Medicare beneficiary, to Salama Chiropractic Center for all covered medical services and supplies provided to me during all courses of treatment and care provided by Salama Chiropractic Center and/or its affiliated entities or otherwise at its direction. I understand and agree this Assignment of Benefits will have continuing effect for so long as I am being treated or cared for by Salama Chiropractic Center, and will constitute a continuing authorization, maintained on file with Salama Chiropractic Center, which will authorize and allow for direct payment to Salama Chiropractic Center of all applicable and eligible insurance benefits for all subsequent and continuing treatment, services, supplies and/or care provided to me by Salama Chiropractic Center.

The above-named doctor may use my health care information and may disclose such information to the above-named insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or 3 years from the date signed below.

Please print name of Patient, Parent, Guardian or Personal Representative

Date

Relationship to Patient