New Patient Registration V2

Patient Identification Information

First Name:

Middle Initial:

Last Name:

Date of Birth:

Social Security #:

Contact Information

Home Phone:

Mobile Phone:

Work Phone:

E-Mail:

Address

Street Address (Line 1):

Street Address (Line 2):

City:

State:

Zip Code:

Contact Preferences

So we may better serve you, please choose your preferred method(s) of contact,

Primary Contact Method:

Secondary Contact Method:

New federal regulations regarding Electronic Health Records
now require that we document patient sex, ethnicity,
preferred language, and tobacco use.
(not required, but preferred).

Ethnicity:

Preferred Language:

Sex:

Tobacco Use:

Occupational Information

Occupation:

Employer:

Additional Information

Drivers License #:

State Issued:

Family and Marital Information

Marital Status:

Spouse/Partner's Name:

Number of Children:

Emergency Contact Information

Contact Person:

Primary Number:

Secondary Number:

Special Needs

Do you have any special needs that may require accomodation? Yes No

How were you referred to us?

Please describe your condition: (1000 chars left)

What is the cause of your condition? (1000 chars left)

When Did This/These Conditions Begin?

What makes the condition feel better or worse? (1000 chars left)

Have you had symptoms similar to your current condition in the past? Yes No

Is the Condition Getting: Better Worse Same

Have You Seen Any Other Physician for this Condition? Yes No

Please Provide Physician's Name:

When Were You Seen/How Long Ago?

Treatment Performed or Recommended:

Have You Ever Been Treated by Another Chiropractor? Yes No

Please Provide Chiropractor's Name:

When Were You Seen/How Long Ago?

What Conditions Were You Treated For?

Who is your primary care physician?

Physician Name:

Practice Name:

City:

State:*

Are you currently being treated by any other physician(s)? Yes No

Physcian Name:

Reason:

Are you currently taking any medications? Yes No

Please list each of your medications (Name, Dosage, Frequency, Reason Prescribed, Prescribing Physician): (1000 chars left)

Please list your surgical history (Type of Surgery - Month/Year): (1000 chars left)

Have You Ever Been Involved in a Motor Vehicle Accident? Yes No

Name of Person Responsible For Payment:

Do You Currently Have Insurance? Yes No

Notice of Privacy Practices

Click Here to View or Click Here to Download Matteo Chiropractic's (HIPPA) NOTICE OF PRIVACY PRACTICES.

I understand that my protected health information will be kept private and confidential in accordance with the privacy practices of Matteo Chiropractic, PLLC. Matteo Chiropractic has a detailed document titled “Notice of Privacy Practices”, which contains additional, detailed information about the policies and practices protecting patient privacy.

I understand that I have the right to request, and to read the “Notice of Privacy Practices” before signing this Acknowledgement or any time thereafter. Within the "Notice of Privacy Practices" is contained a complete description of my privacy/confidentiality rights.

By entering my first and last name below, and selecting the "I understand and agree to the Notice of Privacy Practices" check-box indicates that I have been informed of, and understand my rights to review the “Notice of Privacy Practices”, and that I agree to the “Notice of Privacy Practices” for Matteo Chiropractic, PLLC.

I Understand and Agree to the ELECTRONIC SIGNATURE AGREEMENT. I Understand and Agree to the NOTICE OF PRIVACY PRACTICES.

First Name:* Last Name: Date Signed:

Financial Responsibility Agreement

I understand that an insurance company may not pay the full amount of my charges, and that I may be responsible (as a patient, spouse, or the parent of a minor child) for the amount not paid.

I also understand that if I do not have health insurance coverage, or have not provided current or accurate insurance, that I am responsible for payment of any and all charges.

If I have overpaid a balance due on any individual charge billed by Matteo Chiropractic, PLLC, I agree that this overpayment may be transferred to pay on a balance due for another charge unless other arrangements are formally discussed and planned with a member of Matteo Chiropractic's billing staff.

I Understand and Agree to the ELECTRONIC SIGNATURE AGREEMENT. I Understand and Agree to the FINANCIAL RESPONSIBILITY AGREEMENT

First Name:* Last Name: Date Signed:

Assignment of Insurance Benefits Agreement

I hereby assign, transfer, and convey all my rights, title and interest to medical reimbursement under my insurance policy(s) to Matteo Chiropractic, PLLC for professional service(s) rendered in the course of any examination or treatment.

This authorization shall remain valid until revoked, by me, in writing.

It is understood, whether I sign as agent, patient, or as guarantor, that I am directly responsible for, and will pay for any and all services rendered and not covered by my health insurance benefit plan provider.

I Understand and Agree to the ELECTRONIC SIGNATURE AGREEMENT. I Understand and Agree to the ASSIGNMENT OF INSURANCE BENEFITS AGREEMENT

First Name:* Last Name: Date Signed:

Authorization to Release Protected Information

I authorize the health care providers and staff of Matteo Chiropractic,PLLC to release any and all medical, financial, and demographic information that is deemed necessary by my health care provider for the continuation of my health care to other health care providers, facilities, agencies, and financial institutions.

This authorization will remain in effect until revoked, in writing, and I understand my right to refuse this provision on a case by case basis, when, I notify Mateo Chiropractic, PLLC in writing of the exception in advance.

I Understand and Agree to the ELECTRONIC SIGNATURE AGREEMENT. I Understand and Agree to the AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION.

First Name:* Last Name: Date Signed:

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Please Enter Your Email Address Below.

Email Address:

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Matteo Chiropractic ≡ (919) 563-0000 ≡ 941 S Fifth Street, Mebane, NC 27302

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