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OFFICE FORMS

INITIAL HEALTH STATUS
(Chiropractic) Fax: 925-600-8251

MARK AN X ON THE PICTURE WHERE YOU HAVE PAIN OR OTHER SYMPTOMS

DESCRIBE YOUR CURRENT PROBLEM AND HO

Is this?
Current complaint (how you feel today):
How often are your symptoms present?
Can you perform your daily activities?
HAVE YOU HAD SPINAL X-RAYS, MRI, CT SCAN?
Please check all of the following that apply to you:
History of Recent Infection
Recent Fever
HIV/AIDS
Diabetes
Corticosteroid Use
Birth Control Pills
High Blood Pressure
Stroke (date)
Dizziness/Fainting
Numbness in Groin/Buttocks
Urinary Retention
Aortic Aneurysm
Cancer/Tumor
Osteoporosis
Recent Trauma
Prostate Problems
Frequent Urination
Frequent Urination
Pregnancy, # of births
Abnormal Weight
Abnormal Weight
Epilepsy/Seizures
Visual Disturbances
History of Low/Mid Back Pain
History of Neck Pain
Arthritis
History of Alcohol Use
History of Tobacco Use
Surgeries/Medications
Family History:

Thanks for submitting!
We’ll contact this person only in case of emergency.

MEDIA RELEASE

1) I, the undersigned, hereby authorize Up 2 Speed Sports Performance and Therapy to photograph me, take motion pictures of me, take video footage of me, and/or make electronic sound recordings of me (herein referred to as photographic or electronic reproductions).

2) I authorize the use of any such photographic or electronic reproductions of me for any purpose, including, but not limited to educational and other public media as may be deemed appropriate by Up 2 Speed Sports Performance and Therapy (I understand that I may be identifiable from such photographic or electronic reproduction).

PATIENT PRIVACY ACT

This notice describes how chiropractic and medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. In the course of your case as a patient with Up 2 Speed Sports Performance and Therapy we may use or disclose personal information about you in the following ways: -Your protected health information, including your clinical records, may be disclosed to another health provider or hospital if it is necessary to refer you for further diagnosis, assessment, or treatment. -Your health care records as well as your billing records may be disclosed to another party, such as an insurance carrier, an HMO, a PPO, or your employer, if they are or may be responsible for payment of services provided to you. -Your name, address, phone number, and your health records may be used to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information that may be of interest to you. You have the right to request restrictions on our use of your protected health information for treatment, payment, or operation purposes.

 

Such requests are not automatic and require the agreement of this office. I understand that this office uses an open treatment area and I may be treated in front on other patients. I may request a private room to be used for my treatment. Health information or information about my case may be discussed in front of the other chiropractors in the office or the office receptionist. A private room can be requested to discuss any health information about yourself. If you are not at home to receive an appointment reminder or other related information, a message may be left on your answering machine or with a person in your household. You have the right to confidential communications and to request restrictions relative to such contacts. You also have the right to be contacted by alternative means or at alternative locations.

 

We are permitted/may be required to use or disclose your health information without your authorization in these following circumstances: -If we provide health care services to you in an emergency. -If we are required by law to provide care to and we are unable to obtain your consent after attempting to do so. -If there are substantial barriers to communicating with you, but in our professional judgement, we believe that you intend for us to provide care. -If we are ordered by courts or ano

SSIGNMENT OF INSURANCE PAYMENT PAID DIRE

This is an agreement that any payment from your insurance company that is sent directly to the patient should be sent to Dr. Michael A. Sanchez. It is the patient's responsibility to sign over the check and forward it to Dr. Michael A. Sanchez within 3 days of receiving the payment.

Please forward to: Up 2 Speed Sports Performance and Therapy 7090 Johnson Dr. Pleasanton, CA 94588

ASSIGNMENT OF INSURANCE PAYMENT PAID DIRECTLY TO PATIENT

This is an agreement that any payment from your insurance company that is sent directly to the
patient should be sent to Dr. Michael A. Sanchez. It is the patient's responsibility to sign over
the check and forward it to Dr. Michael A. Sanchez within 3 days of receiving the payment.


Please forward to: Up 2 Speed Sports Performance and Therapy 7090 Johnson Dr. A Pleasanton, CA 94588


1) I agree that I, the undersigned, am responsible to send payment to Dr. Michael A. Sanchez. 2) I hereby
agree to send payment within 3 days of receiving payment from my insurance company

ARBITRATION AGREEMENT AND INFORMED CONSENT

Article 1: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

Article 2: All Claims Must be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims may arise out of or relate to treatment or services provided by the health care provider including any heirs or past, present or future spouse(s) of the patient in relation to all claims, including loss of consortium. This agreement is also intended to bind any children of the patient whether born or unborn at the time of the occurrence giving rise to any claim. This agreement is intended to bind the patient and the health care provider and/or other licensed health care providers or preceptorship interns who now or in the future treat the patient while employed by, working or associated with or serving as back-up for the health care provider, including those working at the health care provider?s clinic or office or any other clinic or office, whether signatories to this form or not. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the health care provider, and/or the health care provider?s associates, association, corporation, partnership, employees, agents and estate, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. This agreement is intended to create an open book account unless and until revoked.

Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days thereafter. Each party to the arbitration shall pay such partys pro rata share of the expenses and fees of the neutral arbitrator, together with.

CANCELLATION POLICY/NO SHOW POLICY

We understand that there are times when you must miss and appointment due to emergencies or obligations for work or family. However

We ask that you please reschedule or cancel at least 24 hours before the beginning of your appointment or you may be charged a cancellation fee of 100% the price of your scheduled appointment. 24 Hour Cancellation to avoid full cost of service.
1) I, the undersigned, have read and fully understand the above agreement.

Thanks for submitting!

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