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Fakhoury Medical & Chiropractic Center

Ocala Chiropractor

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Car Accident? Pain?

Call us

New Medical Paperwork

Updated Intake Form

Step 1 of 18

5%
Name(Required)
MM slash DD slash YYYY
Address(Required)
Emergency Contact
Name
Is there a chance you could become pregnant?
MM slash DD slash YYYY
Are you currently breastfeeding?
Employment Status
Duties
Have you missed any work?
MM slash DD slash YYYY
Have you had any of the following tests?
Have you had any of the following tests?
Consent(Required)
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. I understand and agree that all services rendered to me are changed directly to me and I am personally responsible for payment. In the case insurance verification is obtained, insurance claims may be filed. I understand that the filing 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 to me prior to my termination of care will be immediately due and payable. In the extent of default, I promise to pay legal interest on the indebtedness together with suck 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 my knowledge.
Clear Signature
How would you describe your pain? Check all that apply
Over the past few days/weeks, is your pain:
What worsens or aggravates the pain? Check all that apply
What reduces or alleviates the pain? Check all that apply
Has this affected your sleep?
Do you feel rested upon waking up?
What medications are you taking including over the counter?
Current Medication Name
Dose
Frequency
This medication is for?
 
What is your past/current medical history? Check all that apply
What is your past surgical history?
Surgery (appendix, gallbladder removal, hernia, etc.)
Date of surgery
 
Does your family history include?
What activities have you had difficulties performing since your injury or accident? Check all that apply.
Have you had any of the following symptoms within the past month? Check all that apply
HEENT
Genitourinary
Musculoskeletal
Cardiopulmonary
Constitutional
CNS
Endocrine
Skin
Mental Health
Gastrointestinal
Medical Records Release/Request Form(Required)
By signing this form, I authorize you to release confidential health information about me, by releasing a copy of my medical records, or a summary or narrative of my protected health information to the physician/person/facility/entity of Fakhoury Medical and Chiropractic Center
Clear Signature
Signature for medical release form
The information you may release subject to this signed release form is as follows:(Required)
Health Insurance – Assignment of Benefits(Required)
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 or services and supplies provided.

I understand that I’m responsible for my copayments or deductibles got clobbered by 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 or 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 alll attorneys’ 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 subjects insurance policy.

I agree that Fakhoury Medical and Chiropractic Center May yet retain any attorney it chooses to bring the legal action against any insurance carrier obligated to provide benefits for services and supplies I have received, and that the attorney chosen needs a different than any attorney I may have handling any claim.

I may be given a copy of this assignment to retain if the requested; I have read this assignment and I’m satisfied that I fully understand the purpose and implications of executing this assignment and do sell freely and voluntarily
Clear Signature
Health Insurance Assignment of Benefits
HIPAA Right of Access Form for Family Memeber/Friend(Required)
I direct my Health Care &Medical Services providers and payers to disclose and release my protected health information described below to:
Health information to be disclosed upon the request Of the person named above
HIPAA Choices
Form of Disclosure (unless another format is mutually agreed upon between my provider and designee):
This authorization shall be effective until (check one)
Consent to use or disclose information for treatment, payment or health care operations(Required)
The patient here by consents to the use or disclosure of his or her individually identifiable health information ” protected health information” by Fakhoury Medical and Chiropractic Center 1009 SW 16th Lane Ocala FL 34471, in order to carry out treatment, payment, healthcare 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 or protected health information at anytime. If the FMCC does not change the terms or kits 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 or her protecting health information is used or disclosed to carry out treatment, payment, or healthcare operations. FMCC is not require to agree to such requested restrictions; however, if FMCC does agree to that patience for questing 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 affected except to the extent that the FMCC as already taken action in reliance on the consent.

FMCC May refuse to treat the patient if he or she (or an authorized representative) does not sign this consent form (except to extend that the FMCC is required by law to treat individuals). If the patient 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 understand this information. I have received a copy of this form and I’m the patient, or am authorized to act on behalf of the patient to signed this document, verifying consent to the above stated terms.
Clear Signature
consent to use or disclose information policy

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Find Us!

Hours of Operation

Our Office Hours Are As Follows:

  • Monday 7:30 to 6:00
  • Tuesday 7:30 to 6:00
  • Wednesday 7:30 to noon
  • Thursday 7:30 to 6:00
  • Friday 7:30 to 6:00

Contact Us

Phone: (352) 351-3413
Fax: (352) 629-6667
Address:1009 SW 16th Lane

Ocala, FL 34471

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