New Patient Form


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Work Comp and MVA ONLY

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Is an attorney involved

Patient Information

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Are you pregnant?
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Desk Job?(Required)
Prolonged Sitting/Standing(Required)
Did you have an accident?
Type of accident
Did you have surgery?
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How would you rate your pain on a scale of 1-10?
(0 = No Pain, 10 = Severe Pain)
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I authorize the release of any information pertinent to my case to any physicians, rehabilitation consultants, insurance company, adjuster or attorney involved in my case.
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* Your insurance is a contract between you and your insurance company. We are not a party to that contract. You will be responsible for paying for your visits until your deductible is met. Once your deductible is met, you will be responsible for your co-pay or co-insurance.* As a courtesy, we will verify your benefits with your insurance company. A quote of benefits is not a guarantee of benefits or payment. Your claim will process according to your plan. If your claim processes differently from the benefits we were quoted, the insurance company will side with the plan and will not honor the benefit quote we received.* If you have more than one insurance, you will be responsible for disclosing all insurances to us, as well as alerting each insurance of any additional coverages. Should you neglect to disclose this to any of the parties (the clinic or your insurances), claims could process incorrectly. You will be responsible for any unpaid claims that are the result of a lack of coordination of benefits.* The estimate provided at time of service is not an exact calculation of your actual costs and does not reflect all the terms, conditions, limitations, and exclusions that may apply to your coverage. Your actual costs will vary depending upon the specifics of your benefit plan and the services and supplies you receive.* Not all services are covered in all contracts. Some insurance companies select certain services they will not cover. These services, if applicable, are your responsibility.* Payment is due at time of service. Payments made on account will be applied to the oldest outstanding balance first.* If this injury is work related and a Workers Compensation claim has been initiated, we require that you provide us with a claim # to ensure payment of the account. This must be done on your first visit with us.**We reserve the right to terminate services if payments are not made in a timely fashion.**By signing below, patient/responsible party acknowledges that they read, understands and accepts the above obligations and agreements.
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This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. You have the right to obtain a paper copy of this notice upon request.Patient Health Information: Under federal law, your patient health information is protected and confidential. Patient health information about your symptoms, test results, diagnosis, treatment and related medical information. Your health information also includes payment, billing and insurance information.How we use your Patient Health Information: We use health information about you for treatment, to obtain payment and for health care operations, including administrative purposes and evaluation of the quality of care that you receive. Under some circumstances we may be required to use or discuss the information without your permission.Examples of Treatment, Payment and Health Care Options: We will use and disclose your health information to provide you with medical treatment or services. For example, nurses, physicians and other members of your treatment team with record information in your record and use it to determine the most appropriate course of care. We may also disclose the information to other health care providers who are participating in your treatment, to family members who are assisting with your care.Payment: We will use and disclose your health information for payment purposes. For example, we may need to obtain authorization from your insurance company before providing certain types of treatment. We will submit bills and maintain records of payments from your health plan.Health Care Operations: We will use and disclose your health information to conduct our standard internal operations, including proper administration of records, evaluation of the quality of treatment and to access the care and outcomes of your case and others like it.Special Uses: We may use your information to contact you with appointment reminders. We may also contact you to provide information about treatment alternatives or other health related benefits and services that may be of benefit to you.Other Uses and Disclosures: We may use or disclose identifiable health information about you for other reasons, even without your consent. Subject to certain requirements, we are permitted to give out health information without your permission for the following purposes: 1. As required by law: we may be required by law to report gunshot wounds, suspected abuse or neglect, or similar injuries or events. 2. Research: we may use or disclose information for approved medical research. 3. Public Health Activities: as required by law, we may disclose vital statistics, diseases, information related to recalls of dangerous products and similar information to public health authorities. 4. Health Oversight: we may be required to disclose information to assist in investigation audits, eligibility for government programs and similar activities. 5. Judicial and Administrative Proceedings: We may disclose information in response to an appropriate subpoena or court order. 6. Law Enforcement Purposes: Subject to certain restrictions, we may disclose information required by law enforcement officials. 7. Deaths: We may report information regarding deaths to coroners, medical examiners, funeral directors and organ donation agencies. 8. Serious Threat to Health or Safety: We may use and disclose information when necessary to prevent a serious threat to your health and safety of the health and safety of another person. 9. Military or Special Government Functions: If you are a member of the armed forces, we may release information as required by the military command authorities. We may also disclose information to correctional institutions or for national security purposes. 10. Workers compensation: we may release information about you for workers compensations or similar programs providing benefits for work related injuries or illnesses. IN any other situation, we will ask you for your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization to stop any future uses and disclosures.Individual Rights: You have the following rights, with regard to your health information. Please contact the person listed below to obtain the appropriate form for exercising these rights. Request Restrictions: You may request restrictions on certain uses and disclosures of your information. We are NOT required to agree to such restrictions, but if you do agree, we may abide by those restrictions. Confidential Communications: You may ask us to communicate with you confidentially by, for example, sending notices to a special address. Inspect and Obtain copies: In most cases, you have the right to look at or get a copy of your health information. There may be a small charge for the copies. Amend Information: If you believe that information in your record is incorrect, or if important information is missing, you have the right to request that we correct the existinginformation or add the missing information. Accounting of Disclosures: You may request a list of instances where we have disclosed health information about you for reasons other than treatment, payment or health care operations.Our Legal Duty: We are required by law to protect and maintain the privacy of your health care information, to provide this Notice and our legal duties and privacy practices regarding protected health information and to abide by the terms of the Notice currently in effect.Changes in Privacy Practices: We may change our policies at any time. Before we make a significant change in our policies, we will change our Notice and post the new Notice in the waiting area and each exam room. You can also request a copy of our Notice at any time.Complaints: If you have any concerns, that we have violated your privacy rights, or if you disagree with a decision we made about your records, you may contact the person listed below. You may also send a written complaint to the U.S. Department of Health and Human Services. The person listed below will provide you with the appropriate address upon request. You will not be penalized in any way for filing a complaint.Contact Person:Ascent Therapy Clinics9116 W Bowles Ave #10Littleton, CO 80123Phone: 303-978-9200I hereby acknowledge receipt of this Notice of Privacy Practices.

Cancellation Policy

Our office requires a 24-hour notice for cancellation of appointments; you can call and leave a message on the answering machine if needed. We understand conflicts with work, other activities, or unexpected illness may require you to call and reschedule, however, there may be a $80.00 charge for a missed appointment without notification to the office.
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