SOBRE USTED. Por favor decriba el dolor y su locacion:

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1 uno Bienvenido BACK IN MOTION CHIROPRACTIC dos SOBRE USTED Fecha de Hoy / / Nombre: _ SS#: Masculino Femenino Fecha de nacimiento: / / Edad: Dirección de casa: Ciudad Estado Código postal Telefono de casa#: Teléfono celular #: Dirección de correo electrónico: Empleador: Ciudad, Estado: Cuanto tiempo? Ocupación: Teléfono de Trabajo: Estado civil: Soltero Tiene pareja Divorciado Viudo Paraja: Empleador du su pareja: A quién podemos agradecer por referirlo aqui? SEGURO Quién es responsable de esta cuenta? Relación con el Paciente Compañía de seguros Numero de poliza: Grupo #: Tiene el paciente por el seguro adicional? Sí No El Nombre del Suscriptor Fecha de nacimiento: / / SS# Relaciónal Paciente: _ Compañía de seguros Numero de poliza: Grupo #: ASIGNACIÓN Y LIBERACIÓN Yo, el abajo firmante certifica que (o mi dependiente) tengo la cobertura de seguros con y adjudico directamente al doctor todas las ventajas de seguros, si alguno, por otra parte pagadero a mí para los servicios dados. Entiendo que soy económicamente responsable de todos los gastos del pagado del seguro. Por este medio autorizo al doctor para liberar toda la información necesaria de asegurar los beneficios del pago. Autorizo el uso de esta firma en todas las sumisiones de seguros. Firma de Pla persona Responsible: Relación: Fecha: RAZÓN DE LA VISITA Ha sido tratado alguna vez usted por un quiropráctico antes? Si No Quien fue el doctor? Telefono: La razon de esta visita es: (por favor cicule) Trabajo, accidente de auto, de portes, trauma, cardes, o cronico Explique: Por favor decriba el dolor y su locacion: Cuando comenzo esta condicion? / / Es la condicion peor ahora? Si No Constante Viene y va La condicion interfiere con su: (Por favor circule) trabajo, sueno, o rutina diaria Explique: Ha usted tenido se condiciones similares en pasado? Si No Explique: Ha sido tratado por un doctor para esta condicion: Si No Donde? Tipo de dolor: Agudo Presion Adormeciento Doloroso Fuerte Quema Tintineo Calambre Tenso Inflamado Otro tres Continua atras 6303 Oleander Drive, Suite 102-A ~ ~ Office : ~ Fax:

2 cuatro EN CASO DE EMERGENCIA A quien debemos contactor? Relacion: Numero telefono: telefono trabajo: Quienes su doctor? telefono#: _ HISTORIA DE SU SALUD Nombre las mediciones y/o supplementos que esta tomando ahora: Have you EVER had any of the following diseases/ medical conditions? AIDS/HIV Difficulty Breathing Headaches Alcoholismo Difficulty Hearing High Blood Pressure Anemia Difficulty Seeing Kidney Disease Anorexia/Bulimia Difficulty Swallowing Liver Disease Appendicitis Difficulty Urinating Multiple Sclerosis Arthritis Difficulty w/ bowel Pneumonia Artificial Bones/Joints movements Psychiatric Care Asthma Emphysema Emphysema Stroke Bleeding Disorders Epilepsy Thyroid Problems Bronchitis Fibromyalgia Tonsillitis Cancer Heart Disease Tuberculosis Chemical Dependency Hepatitis Ulcers Diabetes Hernia Please list any other serious medical condition(s) you have or had: List pervious hospitalizations/surgeries with dates: List any past serious accidents with dates: Family Health history: Do You? Smoke Drink Alcohol Drink Coffee/Caffeine Have High Stress Level Packs/Day Drinks/Week Cup/Day Reason For Women: Are you taking Birth Control? Yes No Are you Pregnant? No Yes/How Long? Nursing? Yes No 1 st day of last menstrual period: cinco seis Le invitamos a hablar con nosotros de cualquier pregunta en cuanto a nuestros servicios. La mejor Seguridad Social está basada en un entendimiento amistoso, mutuo entre el abastecedor y el paciente. Nuestra política requiere el pago en su totalidad para todos los servicios dados en el momento de la visita, a menos que otros arreglos hayan sido hechos con el director ejecutivo. Si la cuenta no es pagada 90 días después de la fecha del servicio y ningunos arreglos financieros han sido hechos, usted será responsable de honorarios de abogados, honorarios de agencia de colección, y cualquier otro gasto incurrido en el recogimiento de su cuenta. Autorizo el personal para realizar cualquier servicio necesario durante el diagnóstico y el tratamiento. También autorizo al abastecedor y/o la organización de cuidado para, liberar cualquier información requerida y tratar reclamaciones de seguros. Entiendo la susodicha información y garantizo que esta forma fue completada correctamente al mejor de mi conocimiento y entend que es mi responsabilidad informar a oficina de cualquier cambio de mi estado médico. Nombre Firma Fecha / / Dr. Signature Fecha / /

3 BACK IN MOTION CHIROPRACTIC 6303 OLEANDER DRIVE, SUITE 102-A OFFICE: (910) Fax: (910) Dr. Gina D. Policari Dr. Michael B. Rosen FINANCIAL AGREEMENT I hereby authorize and direct any and all insurance carriers, attorneys, agencies, governmental departments, companies, individuals, and/or other legal entities ( Payers ), which may elect or be obligated to pay, provide, or distribute benefits to me for any medical conditions, accidents, injuries, or illnesses, past, present, or future ( condition ) to pay directly and exclusively in the name of Back in Motion Chiropractic, Inc. such sums as may be owing to Back in Motion Chiropractic, Inc. for charges incurred by me at the office relating to my condition, with such payments to be made exclusively in the name of Back in Motion Chiropractic, Inc. I further grant a lien to Back in Motion Chiropractic, Inc. with respect to my charges. This lien shall apply to all payers and to the full extent permitted by law. For the purposes of this document (herein, Assignment and Lien ), benefits shall include, but not be limited to proceeds from any settlement, judgment, or verdict, as well as proceeds relating to commercial health or group insurance, attorney retainer agreements, medpayments, personal injury protection, no fault coverage, uninsured and underinsured motorist coverage, third party liability distributions, disability benefits, workers compensation benefits, and any other benefits or proceeds payable to me for the purposes stated herein. In the event that I retain one or more attorneys to represent me in this matter who are not located in North Carolina, I will direct each attorney to issue a letter of protection to this office regarding my charges, upon issuance. I hereby agree that such a letter(s) of protection cannot be revoked or modified with out the expressed written consent of this office. I authorize this office to release any information regarding my treatment or pertinent information to my case(s) to all payers as defined above to facilitate collection under this assignment and lien. I further authorize and direct all payers to release to Back in Motion Chiropractic, Inc. information regarding any coverage or benefits which I may have including, but not limited to, the amount of coverage, the amount paid thus far, and the amount of any outstanding claims. I hereby direct this office to file a copy of this assignment and lien, together with any applicable charges, with any or all payers, regardless of whether a claim has been established with said payers. I authorize Back in Motion Chiropractic access to my personal credit file, at anytime if need warrants. I hereby authorize Back in Motion Chiropractic to endorse/sign my name on any and all checks listing me as payee, which are presented to this office for payment of an account relating to me, my spouse or any of my dependents. I further authorize Back in Motion Chiropractic, Inc. to apply any credit balances on charges incurred by me to any other outstanding charges still owed by me, my spouse, or my dependents, regardless of these other charges are related to my conditions. I understand that I remain personally responsible for the total amounts due to Back in Motion Chiropractic, Inc. for their services. This assignment and lien does not constitute any consideration for this office to await payments and it may demand payments from me immediately upon rendering services at its option. If this office must take action to collect an outstanding balance on my account, I will be responsible for payment and will reimburse Back in Motion Chiropractic, Inc. for all costs of such collection efforts, including, but not limited to all court costs and all attorney fees. I am aware outstanding balances greater than 30 days old will begin to accrue interest at a rate of 1.33% per month (16% APR) until the balance is paid in full. This assignment and lien shall not be modified or revoked without the mutual written consent of Back in Motion Chiropractic, Inc. and myself. I hereby revoke any previously signed authorizations, whether executed at this office or any other office to the extent that the terms of those authorizations conflict with the terms of this assignment and lien. Patient Name: (please print) Patient Signature:_ Date: Name of Custodial Parent or Legal Guardian: (Please Print) Parent/ Guardian Signature: Date:

4 Dr. Gina D. Policari BACK IN MOTION CHIROPRACTIC 6303 OLEANDER DRIVE, SUITE 102-A OFFICE: (910) Fax: (910) Dr. Michael B. Rosen Notice of Privacy Practices for Protected Health Information I understand, under the Health Portability and Accountability Act of 1996 ( HIPAA ), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used for: 1. Back In Motion Chiropractic or a staff member to disclose your health information including all of your clinical records to another health care provider or a hospital if it is necessary to refer you to them for diagnosis assessment, or treatment of your health condition. 2. Our insurance and billing staff to disclose your examination and treatment records and your billing records to another party, such as an insurance carrier, an HMO, a PPO, or your employer, if they are potentially responsible for the payment of your services. 3. Back In Motion Chiropractic and members of the staff to use your health information, examination, treatment records, and your billing records for quality control purposes or for other administrative purposes to efficiently and effectively run our practice. 4. Back In Motion Chiropractic and members of the practice staff to use your name, address, phone number, and your clinical records to contact you to provide appointment reminders, birthday cards, holiday cards, newsletters, information about treatment alternatives, or other health related information that may be of interest to you (b)(1)(iii)(A). If you are not home to receive an appointment reminder, a message will be left on your answering machine or with whomever answers the phone. I have received, read and understand your Notification of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that Back In Motion Chiropractic has the right to change its Notification of Privacy Practices from time to time and that I may contact Back In Motion Chiropractic at any time to obtain a current copy of the Notification of Privacy Practices. I understand that I may request in writing, that you restrict how my privacy information is used or disclosed to carry out treatment, payment, or health care operations. I also understand you are not required to agree to my restrictions, but if you do agree then you are bound to abide by such restrictions. I do allow the following people to have access to my health records: Patient Name: Relationship to Patient: Signature: Date: ********************************************************************************************************************************************* OFFICE USE ONLY I attempted to obtain the patient s signature in acknowledgment to this Notice of Privacy Practices Acknowledgement, but was unable to do so as documented below: Date: Initials:

5 BACK IN MOTION CHIROPRACTIC 6303 Oleander Drive, Suite 102-A Date: Patient Name: Date of Birth: HOW DOES YOUR SPINE FEEL TODAY? (Please Circle) GREAT VERY BAD Please mark areas of pain or injury on the illustrations below and give a description of the symptoms you are experiencing in those areas: