Automobile Insurance Information

Automobile Insurance Company(Required)

Claim Number(Required)

Policy Number(Required)

Insurance Company Phone Number(Required)

Adjuster's Name(Required)

First Last

Adjuster's Phone(Required)

Attorney's Name(Required)

First Last

Attorney's Phone(Required)

FINANCIAL STATEMENT:

I fully understand that I am solely responsible for charges from services rendered and/or any balance not paid by my insurance company. I authorize the staff to perform any necessary services during diagnosis and treatment. I also authorize the provider and/or managed care organization to release any information required to process insurance claims. The information I have provided is true and accurate to the best of my knowledge.

Signature

(You will wet sign this form after it is printed)

Date

350 West John Sims Parkway Suite 401

Niceville, Florida, 32578

(850) 678-8049 (P) / (850) 678-2629 (F}

TaxlD:47-2900758

Patient Name(Required)

First Last

Assignment of Insurance Benefits

I hereby authorize payment to be made directly to Russell Chiropractic, Inc. of all benefits that may be due and payable under insurance coverage for the above-named patient. I authorize the utilization of this application or copies thereof for the purpose of processing claims and effecting payments. I further acknowledge that this assignment of benefits does not in any way relieve you of liability and that I will remain financially responsible to Russell Chiropractic. Furthermore, I hereby IRREVOCABLY ASSIGN to Russell Chiropractic the rights and benefits under any policy of insurance, indemnity agreement, or any other collateral source as defined in Florida Statutes for any services and or charges provided by Russell Chiropractic, LLC.

Authorization to Release Medical Record Information

Russell Chiropractic is hereby authorized to disclose all or any part of the medical records on the above-named patient to such insurance companies, organizations, or agencies as may be responsible for payment of services rendered by Russell Chiropractic. This authorization is given with full knowledge that such disclosure may contain information of a confidential nature and may result in a denial of insurance coverage for services rendered by said Russell Chiropractic. The undersigned certifies that he/she has read and understands each of the above paragraphs and is the patient or responsible party with the power to execute this document and accept these terms.

Signature

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Date

Informed Consent

REGARDING: Chiropractic Adjustments, Modalities, and Therapeutic Procedures
I understand that chiropractic care, like all forms of health care, holds certain risks. While the risk are often very minimal, in rare cases, complications such as sprain/strain, injuries, irritation of a disc condition, and although rare, minor fractures, and possible stroke, which occurs at a rate between one instance per one million to one per two million, have been associated with Chiropractic adjustments.
Treatment objectives as well as the risks associated with Chiropractic adjustments and all other procedures provided at Russell Chiropractic have been explained to me to my satisfaction and I have conveyed my understanding of both to the doctor. After careful consideration, I do hereby consent to treatment of any means, method, and or techniques the doctor deems necessary to treat my condition at any time throughout the entire clinical course of my care.
Please enter your initials and the date below to confirm that you have read this notice and agree.

Initials(Required)

Date(Required)

REGARDING: X-rays/ imaging Studies FEMALES ONLY: please read carefully and check the boxes, include the appropriate date, then sign below if you understand and have no other questions, otherwise see our receptionist for further explanation

The first day of my last menstrual cycle was:(Required)

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Pregnant

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MVA Patient Paperwork

Automobile Insurance Information

FINANCIAL STATEMENT:

Vehicle Accident Information

Accident Site

Your Vehicle Information

Other Vehicle Information

Police

Patient Condition

Impact

Treatment

Symptoms / Injuries

Prior Injuries

Past or Current Conditions

Social History

Family History

Conditions

Informed Consent

Russell Chiropractic

Location

Office Hours

Contact

(850) 678-8049