Health Insurance or Self Pay Forms

Name:

Nickname:

Address:

MaleFemale
City/State/Zip:

Birth date:

Age:

SS#:

Home Phone:

Work Phone:

Mobile Phone:

Email:

Employer:

Occupation:

Emergency Contact:

Telephone:

Marital Status:
SingleMarriedDivorcedWidowed
Spouse's Name:

Ethnicity:
WhiteAfrican AmericanHispanic/LatinoAsianOtherDecline to answer
Which of the following activities aggravate your condition (Please check all that apply):
StandingSleepingTwistingSittingBendingLiftingWalkingSneezingCoughingLying DownSexual ActivityOther
Are the symptoms:
ImprovingGetting WorseAbout the sameIntermittent (come & go)

I clearly understand that if I am accepted as a patient at Fakhoury Medical and Chiropractic Center, I authorize them to proceed with the treatment as necessary. Any risks regarding such treatment will be explained upon request. I also understand and agree that all services rendered to me are charged directly to me and I am personally responsible for payment. In the case insurance verification is obtained, insurance claims may be filled. I understand that the filling of insurance is not a guarantee of payment, and I remain responsible for the entire amount due. I also understand that if I terminate my care and treatment, any fees for professional services rendered me prior to my terminator of care will be immediately due and payable. In the extent of default, I promise to pay legal interest on the indebtedness together with such collection costs and reasonable attorney fees as may be required to effect collection. I hereby attest that the above and all following information is true to the best of knowledge.

Date:

Signature:

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Witness Signature:

[signature customer-witness cols:500 rows:200]

Date:

Patient Name:

Acct#:

Date:

Today's Chief Complaint:

Have you seen another Doctor for this condition?

Name of Doctor:

Have you had any X-rays, MRis, CTs or Ultrasounds for this condition?

Where?

Name of your Primary Care Doctor?

Is this condition due to:
Auto AccidentWork RelatedFall
Other:

Date of Accident:

Were you treated at the ER?:

Name of Facility:

Were MRIs, CTs, Ultrasounds or X-rays done:

Where?

ACTIVITIES OF DAILY LIVING:
EatingBathingToiletingTransferringDressingGroomingSleepingThinkingSittingWalkingStairsReachingLiftingBendingStoopingKneelingSquattingGraspingWeakness
Where?

Medications?

List Allergies:

Past Medical History:
Have you had any of the following problems?
AsthmaBowel disorderCancerDepressionDiabetesBladder disorderHeart diseaseKidney diseaseLung diseaseBronchitisTuberculosisStrokePolioHigh Blood pressureRheumatismSeizureMental IllnessThyroidUlcer
Other:

Past surgical History:

Family History: Do you have a family history with any of the following
DiabetesRheumatoid arthritisBack problemsCancerTuberculosisHeart AttacksHypertension
Other:

Social History: Smoker? Y/N
Packs per day:

Alcohol use? Y/N #:
drinks per week
Work History: Describe your job duties:

Fakhoury Medical and Chiropractic Center
1009 SW 16th Lane Ocala, FL 34471 (352) 351-3413 Fax (352) 629-6667
HEALTH INSURANCE - ASSIGNMENT OF BENEFITS
The insured assigns all of the rights and benefits of any applicable Medical Payments, or other coverage provided by any insurance policy issued to Fakhoury Medical and Chiropractic Center for services and supplies provided.
I understand that I am responsible for any co-payments or deductibles not covered my Health insurance coverage.
This assignment includes, but is not limited to: All rights to collect benefits directly from any insurance carrier obligated to provide benefits for services and supplies I have received. All rights to take legal or other action against any insurance carrier obligated to provide benefits if for any reason the insurance carrier fails to pay any benefits due; and All rights to recover attorney fees, legal assistant fees, costs, and any interest on fees and costs, for any legal or other action taken by Fakhoury Medical and Chiropractic Center as my assignee.
This is an assignment of rights only, and is not a delegation of any of my duties under the subject insurance policy.
I agree that Fakhoury Medical and Chiropractic Center may retain any attorney it chooses to bring legal action against any insurance carrier obligated to provide benefits for services and supplies I have received, and that the attorney chosen may be different than any attorney I may have handling any claim.
I may be given a copy of this assignment to retain for my records if requested; I have read this assignment and I am satisfied that I fully understand the purpose and implications of executing this assignment and do so freely and voluntarily.

Print Name:

Date Signed:

[signature signature-388 cols:400 rows:200]

Date Signed:

Fakhoury Medical & Chiropractic Center PLLC
1009 S.W 16th Lane Ocala, Florida 34471
Phone 352-351-3413 fax 352-629-6667

Review of Systems
Date:

Please check ALL symptoms you have recently experienced:
I. HEENT -
double visionblurred visionringing in the earsdizzypoor hearingsevere headachesevere recurrent nose bleeddifficulty swallowing
II. CARDIOPULMONARY -
dull chest painpressure/tightnesschest palpitations (fluttering)shortness of breath at restshortness of breath with exertionshortness of breath when lying flatcoughingcoughing up bloodswelling feetsevere sweating at night
III. GASTROINTESTINAL -
abdominal painvomitingvomiting bloodblack & tarry stoolbloody stoolsclay colored stoolsloss of bowel controldramatic change in bowel habitsjaundice (yellowing of skin, eyes)
IV. GENITOURINARY -
burning on urinationblood in urineunitary frequencyloss of bladder controlpenile or vaginal dischargepenile or vaginal bleedinggenital sores
V. MUSCULOSKELETAL -
joint painjoint swellinggrinding of jointslocking of jointsneck painback pain
VI. CONSTITUTIONAL -
feverchillsnight sweatsloss of appetiteunintentional weight loss
VII. CNS -
Paralysis in arms or legsnumbness in arms or legsloss of consciousnessseizurestremorsjerkingpoor coordination
VIII. SKIN -
loss of hairdry sores locationitchinessrashes
IX. ENDOCRINE -
increase thirstexcessive urinationexcessive drinkinghot/cold intoleranceexcessive sweating
Patient Signature:
[signature signature-643 cols:400 rows:200]

CONSENT TO USE OR DISCLOSE INFORMATION
FOR TREATMENT, PAYMENT OR HEALTH CARE OPERATIONS
The Patient hereby consents to the use or disclosure of his/her individually identifiable health information "protected health information" by Fakhoury Medical and Chiropractic 1009 SW 16th Lane Ocala FL 34471, in order to carry out treatment, payment, or health care operations. The Patient should review FMCC's Notice of Privacy Practices for Protected Health Information "attached" for a more complete description of the potential uses and disclosures of such information, and the Patient has the right to review such Notice prior to signing this consent form.
FMCC reserves for itself, the right to change the terms of its Notice of Privacy Practices for Protected Health Information at any time. If the FMCC does change the terms of its Notice of Privacy Practices, The patient may obtain a copy of the revised Notice by written request.
Patient retains the right to request that FMCC further restricts how his/her protected health information is used or disclosed to carry out treatment, payment, or health care operations. FMCC is not required to agree to such requested restrictions; however, if FMCC does agree to Patient's requested restrictions, such restrictions are then binding on the FMCC.
At all times, Patient retains the right to revoke this Consent. Such revocation must be submitted to the FMCC in writing. The revocation shall be effective except to the extent that the FMCC has already taken action in reliance on the Consent.
FMCC may refuse to treat Patient if he/she (or an authorized representative) does not sign this Consent Form (except to the extent that the FMCC is required by law to treat individuals). If Patient (or authorized representative) signs this Consent Form and then revokes Consent, the FMCC has the right to refuse to provide further treatment to Patient as of the time of revocation (except to the extent that the FMCC is required by law to treat individuals).
I wish to have the following restrictions to the use or disclosure of my health care information:

I HAVE READ, ACCEPTED AND I UNDERSTAND THIS INFORMATION. I HAVE RECEIVED A COPY OF THIS FORM AND I AM THE PATIENT OR AM AUTHORIZED TO ACF ON BEHALF OF THE PATIENT TO SIGN
THIS DOCUMENT VERIFYING CONSENT TO THE ABOVE STATED TERMS.

Signature of Patient: [signature signature-192 cols:400 rows:200]
Date:

Please print name:
Signature of witness:
[signature WitnessSignaturepage5 cols:400 rows:200]
Date:

Fakhoury Medical and Chiropractic Center

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