CHIROPRACTIC REGISTRATION
1
AND
HISTORY
PATIENT INFORMATION
Patient Name
Employer / School
Last Name
Occupation
First Name
Middle Initial
Employer / School Address
Address
City
Employer / School Phone
State
Zip
Cell Phone (
Home Phone
 M
Spouse’s Employer
(
)
 F
IN CASE OF EMERGENCY, CONTACT
Name
Age
Birthdate
 Married
 Widowed
 Single
 Separated
 Divorced
 Partnered for
2
)
Spouse’s Name
)
Social Security Number
Sex
(
Relationship
Home Phone (
)
Work Phone (
)
 Minor
Whom may we thank for referring you?
years
PATIENT CONDITION
Reason for visit (please be very specific):
When did your symptom appear?
Is this condition getting progressively worse?
 Yes
 No
 Unknown
Mark an X on the picture where you continue to have pain, numbness, or tingling:
Rate the severity of your pain on a scale of 1 (least pain) to 10 (severe pain)
Type of pain:
 Sharp
 Dull
 Throbbing
 Numbness
 Aching
 Shooting
 Burning

 Cramps

 Swelling

Tingling
Stiffness
Other
How often do you have this pain?
Is it constant or does it come and go?
Does it interfere with your
 Work
 Sleep
Activities or movements that are painful to perform:
3

Daily Routine
 Sitting

INSURANCE INFORMATION
Insurance Co.

Recreation
Standing
 Walking
4
 Bending
 Laying Down
ACCIDENT INFORMATION
Is this consultation due to an accident?  No  Yes
ID #
Is Patient covered by additional insurance?
 Yes
 No
If so, what was the date of Accident:
Type of accident  Auto
 Work
 Home
 Other
Subscribers Name________________________________________
To whom have you made a report of your accident?
ASSIGNMENT AND RELEASE
I understand that I may receive a statement of services received and
paid for to submit to my insurance company. I understand that I am
financially responsible for all charges whether or not paid by insurance.
Signature of Patient, Parent, Guardian or Personal Rep
Claim number:

 Auto Insurance  Employer  Worker Comp.  Other
Attorney Name (if applicable)
Address
Please print name of Patient, Parent, Guardian or Personal Representative
Date
Relationship to Patient
Phone
5
HEALTH HISTORY
What health care have you already received for your condition?

Chiropractic Care (Dr.

Medications (Dr.

Other:

None
Date
Date
)
)
 Surgery (Dr.
Date
)

Date
)
Date
)
Physical Therapy (Dr.
(Dr.
Place a mark on “Yes” or “No” to indicate if you have had any of the following:
AIDS/HIV
 Yes  No
Chicken Pox
 Yes  No
Liver Disease
 Yes  No
Rheumatoid Arthritis  Yes  No
Alcoholism
 Yes  No
Diabetes
 Yes  No
Measles
 Yes  No
Rheumatic Fever
 Yes  No
Allergy Shots
 Yes  No
Emphysema
 Yes  No
Migraine Headaches  Yes  No
Scarlet Fever
 Yes  No
Anemia
 Yes  No
Epilepsy
 Yes  No
Miscarriage
 Yes  No
Stroke
 Yes  No
Anorexia
 Yes  No
Fractures
 Yes  No
Mononucleosis
 Yes  No
Suicide Attempt
 Yes  No
Appendicitis
 Yes  No
Glaucoma
 Yes  No
Multiple Sclerosis
 Yes  No
Thyroid Problems
 Yes  No
Arthritis
 Yes  No
Goiter
 Yes  No
Mumps
 Yes  No
Tonsillitis
 Yes  No
Asthma
 Yes  No
Gonorrhea
 Yes  No
Osteoporosis
 Yes  No
Tuberculosis
 Yes  No
 Yes  No
Tumors, Growths
 Yes  No
Typhoid Fever
 Yes  No
Bleeding Disorders  Yes  No
Gout
 Yes  No
Pacemaker
Breast Lump
 Yes  No
Heart Disease
 Yes  No
Parkinson’s Disease  Yes  No
Bronchitis
 Yes  No
Hepatitis
 Yes  No
Pinched Nerve
 Yes  No
Ulcers
 Yes  No
Bulimia
 Yes  No
Hernia
 Yes  No
Pneumonia
 Yes  No
Vaginal Infections
 Yes  No
Cancer
 Yes  No
Herniated Disk
 Yes  No
Polio
 Yes  No
Venereal Disease
 Yes  No
Cataracts
 Yes  No
Herpes
 Yes  No
Prostrate Problem  Yes  No
Whooping Cough
 Yes  No
High Cholesterol
 Yes  No
Prosthesis
 Yes  No
Kidney Disease
 Yes  No
Psychiatric Care
 Yes  No
Chemical
Dependancy
 Yes  No
Other
EXERCISE
WORK ACTIVITY
HABITS

None

Sitting

Smoking
Packs/Day

Moderate

Standing

Alcohol
Drinks/Week

Daily

Light Labor

Coffee/Caffeine Drinks
Cups/Day

Heavy

Heavy Labor

High Stress Level
Reason
PREGNANCY
Are you currently pregnant?

No
 Yes, and I am due
Number of past pregnancies
Children’s Ages:
Child #1
Injuries/Surgeries you have had:
Child #2
Child #3
Description
Child #4
Date
Falls
Head Injuries
Broken Bones
Dislocations
Surgeries
6
MEDICATIONS
ALLERGIES
SUPPLEMENTS
ALLEN CHIROPRACTIC CLINIC
___________DR. MICHAEL R. ALLEN___________
2209 Shed Road
Bossier City, LA 71111
(318) 747-6100 office
(318) 742-3005 fax
Dear patient,
We would like to welcome you to our office. Many people have two concerns when seeing a chiropractor.
Can the doctor really help me?
How much is this going to cost me?
It is our office policy to only accept those patients we sincerely feel we can help. We will do our utmost to provide you with the
most effective, cost efficient care available. The fees below are services that may be provided to you for the rehabilitation of
your health.
Our fees as of October 1st, 2012
Chiropractic initial exam, or re-exam:
X-rays (per film taken)
Spinal manipulations
Missed appointments
Therapeutic exercises
Myo-fascial release
Myo-Pulse therapy
Ice or heat therapy
Manual traction
Copy charges for records
$40.00 - $125.00
$60.00
$35.00
$25.00 (responsibility of patient)
$39.00 (home care, stretching exercises, ect)
$30.00 per 30 minutes
$25.00
$20.00
$25.00
$25.00 (Inquire at the front desk for current fees)
****We offer a time of service discount for services paid in full****
Our office works on a zero balance with our patients. Your insurance may cover all or part of the services performed in this office,
and what is not paid or covered is your responsibility!
If your account falls 30 days overdue, we have the right to charge you a $10.00 late fee on the outstanding amount every 30 days the
balance is overdue. Any account that is 90 days past due will be sent to collections. If your case is not resolved and requires court
interference, you will be personally responsible for any attorney fees, court fees, filing fees, and lien fees and all staff and doctor time
involved.
****PATIENT INITIALS:___________****
ATTENTION MEDICARE PATIENTS:
Allen Chiropractic Clinic staff has informed me that they will assist me in scheduling my care within the Medicare part B guidelines. I
acknowledge that my individual needs and personal schedule may prevent my treatment from always falling within these guidelines.
Should any of the services rendered from Dr. Allen be denied or only partially paid, I acknowledge that I am personally responsible for
the payment to Allen Chiropractic Clinic. I understand that ONLY manipulations are covered under Medicare part B, any extra
services such as exams, x-rays, therapy and massage will be at my sole expense. Also note that with Medicare Supplement insurance,
we will bill Medicare the services performed, and if denied by Medicare, your supplement is not a guarantee of payment for Medicare
denial, in such cases are your responsibility.
Please note*** if your insurance requires a pre-authorization or referral from your primary care physician, it is YOUR responsibility to
obtain this PRIOR to your appointment with Dr. Allen.
I HAVE READ AND FULLY UNDERSTAND THE ABOVE FINANCIAL TERMS AND CONDITIONS
PRINTED PATIENT NAME: _________________________________________________________________
SIGNED: _____________________________________________________ DATE:____________________
ALLEN CHIROPRACTIC CLINIC
___________DR. MICHAEL R. ALLEN___________
2209 Shed Road
Bossier City, LA 71111
(318) 747-6100 office
(318) 742-3005 fax
***EFFECTIVE IMMEDIATELY***
Your appointment time is reserved especially for
you. Please call to cancel at least 24 hours prior to
your scheduled appointment time if you will be
unable to keep your appointment with Dr. Allen or
Frank. If you forget or fail to show up for your
appointment, there will be a $25 fee charged to your
account that is not covered by your insurance, and
will be due before any other services can be
rendered.
___________
Initials
__________
Date
ALLEN CHIROPRACTIC CLINIC
___________DR. MICHAEL R. ALLEN___________
2209 Shed Road
Bossier City, LA 71111
(318) 747-6100 office
(318) 742-3005 fax
STATEMENT OF HIPPA PRIVACY PRACTICE
We, at Allen Chiropractic Clinic, are dedicated to protecting the privacy rights of our patients and the confidential information entrusted in us. The commitment
of our employees and business associates ensure that your health information is never compromised as a principal concept of our practice. We may, from
time to time, amend our privacy policies and practices, but will always inform you of any changes that might affect your rights.
PROTECTING YOUR PERSONAL HEALTH CARE INFORMATION
We use and disclosed the information we collect for you only as allowed by the Health Insurance Portability and Accountability Act and the State of Louisiana.
This includes issues relating to your treatment, payment and our chiropractic care operations. Your personal health information will never otherwise be given
to anyone-even family members-without your written consent. You may give written authorization for us to disclose information to anyone you choose. You
may also instruct us, in writing, NOT to disclose your information to anyone. This will require a separate from along with your signature.
Our office is secure from unauthorized access, and our employees are trained and certified to make certain that the confidentiality of your records are always
protected. Our privacy policies apply to former, current and future patients, so you can be confident that your protected health information will never be
improperly disclosed or released.
COLLECTING PROTECTED HEALTH INFORMATION
We will only request personal information needed to provide our standard of quality chiropractic care, implement payment activities, conduct normal
chiropractic operations and comply with law. This may include your name, address, telephone numbers, and social security number, date of birth, employment
information and medical history. While most health information will be collected from you, we may obtain other information from third parties, if it is deemed
necessary. Regardless of the source, your personal information will always be protected to the full extent of the law.
DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION
As stated above, we may disclose information as required by law. We are obligated to provide information to law enforcement and government
officials under certain circumstances. We will not use your personal information for marketing purposes without your written consent.
We may contact you using your personal information to communicate reminders about appointments, including voice mail messages, answering
machines and post card reminders.
***PATIENT INITIALS:___________***
PATIENT RIGHTS
You have a right to request copies of your health care information, to request copies in a variety of formats and to request a list of instances which we have
disclosed your protected health information for uses other than stated above. All such requests must be in writing and our office may charge for your copies in
an amount allowed by law. If you believe that your rights have been violated, we urge you to notify us immediately. You can also notify the U.S. Department
of Health and Human Services. Your Chief Privacy Officer can be reached at our office any time during normal business hours.
We thank you for being a patient of Dr. Allen and Allen Chiropractic Clinic. Please let us know if you have any further questions concerning your privacy rights
and protection of your personal health information.
____________________________________
Patient’s Name ~ printed
____________________________________________
Patient’s Signature ~ if under 18 a parent or legal guardian must sign
____________________________________
____________________________________________
Signature of Staff ~ Witness
Date
ALLEN CHIROPRACTIC CLINIC
___________DR. MICHAEL R. ALLEN___________
2209 Shed Road
Bossier City, LA 71111
(318) 747-6100 office
(318) 742-3005 fax
CONSENT TO TREATMENT
To our patients,
Chiropractic examination and therapeutic procedures (including spinal adjustment,heat
application, and manual muscle therapy) are considered safe and effective methods
of care. Occasionally, however, complications may arise. Any procedure intended to
help may have complications. While the chances of experiencing complications are
small, it is the practice of this clinic to inform our patients about them. Side effects
include, but are not limited to soreness, inflammation, soft tissue injury, and temporary
worsening of symptoms. More serious complications are extremely rare and their
association with spinal adjustments(manipulations) are debated. These complications
include injury to the arteries in the neck which may be associated with stroke and serious
neurological impairment, injuries to the spinal discs, and spinal fractures. Serious
complications are estimated to be in the range of . – 2 incidents per million adjustments
of the neck and 1 per million for adjustments of the lower back.
I have and understand the above statements regarding treatment side-effects. I also understand
that there is no guarantee or warranty for a specific cure or result.
________________________
Patient Signature
___________________
Date
ALLEN CHIROPRACTIC CLINIC
___________DR. MICHAEL R. ALLEN___________
2209 Shed Road
Bossier City, LA 71111
(318) 747-6100 office
(318) 742-3005 fax
AUTHORIZATION
All the staff at Allen Chiropractic Clinic, Inc. takes your medical confidentiality very seriously.
We will not and cannot release information without your written authorization.
This authorization form, when completed and signed by you allows our staff members to
speak only with individual(s) you designate in the event that you are not available to receive
our phone calls or you have an adult family member that helps coordinate your medical care.
You should not designate a physician.
If you feel comfortable allowing us to talk with another person regarding an appointment or the
other needs listed, you will need to give their information requested below and place a check
next to the items that apply. If you choose not to authorize any other person, you will need to
check that selection below.
*_____I authorize employees of Allen Chiropractic Clinic, Inc. to speak with:
__________________________
Name
__________________________
Name
__________________________
Phone Number
__________________________
Phone Number
____Appointments
____Account/Bill
____Test Results
____Medical Care
____Appointments
____Account/Bill
____Test Results
____Medical Care
Information regarding any of the above may also be left on my voice mail or answering
machine.
_____Yes
_____No
*_____I do not authorize anyone to receive information related to my medical
care.
________________________
Patients Signature
_________________
Date
ALLEN CHIROPRACTIC CLINIC
___________DR. MICHAEL R. ALLEN___________
2209 Shed Road
Bossier City, LA 71111
(318) 747-6100 office
(318) 742-3005 fax
AUTHORIZATION TO RELEASE INFORMATION
I do hereby authorize Allen Chiropractic Clinic, Dr. Michael Allen or any authorized agent of this
clinic to furnish my insurance company, attorney, or its representatives any and all medical
information it may request with respect to any injury or illness suffered by me. This includes
any and all medical history, consultations, treatments, X-rays, and copies of medical records
pertaining thereto. Also, that the same may be included as part of the proof of claim submitted
by me to said insurance company, attorney or their representatives.
_________________________________________________________
_______________________
Patient’s Signature ~ if under 18 a parent or legal guardian must sign
Date
A PHOTOTCOPY OF THIS AUTHORIZATION SHALL BE VALID AND HAVE THE SAME
EFFECT AS THE ORIGINAL.
ASSIGNMENT OF BENEFITS TO THE PHYSICIAN
I do hereby assign the expense benefits allowable, and otherwise payable, to me under my
current insurance policy as payment toward the total charges doe professional services
rendered by Dr. Michael Allen and/or Allen Chiropractic Clinic. This payment shall not exceed
my total debt owed to above named assignee and I have agreed to pay in a current manner, any
balance of above stated professional services charged over and above the insurance payment.
If I fail to pay as stipulated herein, all monies due will be considered delinquent and I will be
responsible for the entire balance due, along with all cost of collections, including but not
limited to, attorney fees of $500.00 PR 25% of total amount due (whichever is greater) and or
collections agency fees of 33.33% of the total amount due, along with all court cost, Marshall
fees and any other cost incurred in the collection of this account.
_________________________________________________________
_______________________
Patient’s Signature ~ if under 18 a parent or legal guardian must sign
Date
A PHOTOTCOPY OF THIS AUTHORIZATION SHALL BE VALID AND HAVE THE SAME
EFFECT AS THE ORIGINAL.
Notifier: Allen Chiropractic Clinic
Patient Name:
Identification Number:
ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE (ABN)
NOTE: If Medicare doesn’t pay for items checked or listed in the box below,
you may have to pay.
Medicare does not pay for everything, even some care that you or your health care provider have good
reason to think you need. We expect Medicare may not pay for the items listed in the box below.
Listed or Checked Items Only:
Reason Medicare
May Not Pay:
Estimated
Cost:
Heat, Electrical stim therapy, new or reexam, radiology films
NON COVERED SERVICES,
MAY BE DENIED NOT
MEDICALLY NECESSARY BY
MEDICARE
$40.00 for the exam
$45.00 for the Heat, Electrical
stim therapy
$60.00 for radiology films
WHAT YOU NEED TO DO NOW:



Options:
Read this notice, so you can make an informed decision about your care.
Ask us any questions that you may have after you finish reading.
Choose an option below about whether to receive the checked items listed above.
Note: If you choose Option 1 or 2, we may help you to use any other
insurance that you might have, but Medicare cannot require us to do
this.
Check only one box.
We cannot choose a box for you.
❏ OPTION 1.
I want the items listed above. You may ask to be paid now, but I also want Medicare billed for an
official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare
doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If
Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.
❏ OPTION 2.
I want the items listed above, but do not bill Medicare. You may ask to be paid now as I am
responsible for payment. I cannot appeal if Medicare is not billed.
❏ OPTION 3.
I don’t want the items listed above. I understand with this choice I am not responsible for
payment, and I cannot appeal to see if Medicare would pay.
Additional Information:
This notice gives our opinion, not an official Medicare decision. If you have other questions on
this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048).
Signing below means that you have received and understand this notice. You also receive a copy.
Signature:
Date:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to
average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the
information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500
Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.
Form CMS-R-131 (03/08)
Form Approved OMB No. 0938-0566