Physical medicine group

Patient Information
Current Medications
Health Overview
Gender: female male marital status: S M D W Ease at tying shoes 0 -------------------- 10 Insurance Guarantor
Sugary food per day 0 -------------------- 10 exercise □ rare □ 1-2x/wk □ dailyVegetable servings Spouse/Partner name
Daily supplements:
□ multivitamin, □ vitamin D, □ calcium If patient is a minor:
I hereby authorize my daughter/son to receive Naturopathic care.
Major events in past 12 months
□ marriage
Emergency contact:
□ sold/purchased a home□ surgery or major il ness What brings you into the office?

Patient Initials, date
Page 1 of 5 Registration package Physical Medicine Group 2010 LEGAL ASSIGNMENT OF BENEFITS AND RELEASE OF MEDICAL AND PLAN DOCUMENTS
Provider – a licensed health care professional employed by the Physical Medicine Group.
Insurance – a policy or contract that reimburses for health services. Insurance includes personal injury
protection, health insurance, and/or employee health benefits. Insurance includes the policy number or
claim number.
In consideration of the medical expenses incurred or to be incurred, I, the undersigned, attest and agree
to the fol owing:
1. Al Insurance I present to the Provider for reimbursement is valid and in effect during the time of
treatment. I agree that I am responsible to inform the Provider with any change in the Insurance
reimbursement policy, and/or changes in my Insurance eligibility status.
2. I authorize the use of this signature to be used by the Provider in the submission of health
3. I assign and convey Insurance reimbursement to be directly released to the Provider. This
assignment retroactively applies to Insurance reimbursement prior to this signature date. This
assignment remains in effect for al future reimbursement, including al future Insurance plans.
4. I authorize the Provider to release al medical information needed to process Insurance claims.
5. I authorize al Insurance plan administrators, fiduciaries, insurers and my attorneys to release
any and al plan documents, insurance policy and/or settlement information upon written request
from the Provider.
6. I agree to cooperate with the Provider in col ection actions against the Insurance company
involving inadequate reimbursement of Provider services. Note that the Provider is responsible
for the cost of col ection.
7. I am financial y responsible, and agree to pay al Provider services not covered by Insurance.
8. I agree to pay al Insurance co-pays, and deductibles, for services that are covered.
9. I agree to the Provider's fee schedule, and cancel ation policy.
This assignment wil remain ful y effective to the maximum legal extent possible until revoked by myself in writing. A photocopy and/or facsimile of this assignment shal be considered as valid as the original. I have read and ful y understand this agreement. Signature of Patient’s Parent/Guardian, on behalf of minor Page 2 of 5 Registration package Physical Medicine Group 2010 CONSENT FOR NATUROPATHIC TREATMENT
General Information:
The practice of Naturopathy is limited in scope. In order to provide complete health care, Naturopathic
Physicians are al ied with conventional medical doctors for hospitalization, treatment of cancer and a
number of other medical issues.
Potential risks for Naturopathy and physiotherapy.
Prescription drug therapy is a complex issue. Be sure to ask questions about any drug therapy.
Physical exam can include examination of body cavities, only when medical y necessary. Blood work, immunization, and vitamin, or other injections involves getting stabbed by a needle. Bleeding, and bruising are to be expected. Injection site is typical y sore and tender about 2 days afterwords. There is some potential of infection. Please advise your practitioner if the site become red, warm and or tender.
X-ray imaging uses ionizing radiation that is known to cause cancer. Joint manipulation has a very low risk of joint damage. Inform your practitioner of joint issues.
Cervical spine (neck) manipulation as a very low risk of injury to the vertebral artery. Please inform your practitioner of artery disease, or high blood pressure.
Ultrasound/diathermy can cause internal burns. Please advise your practitioner if you are experiencing pain. Also advise if treatment areas have nerve damage, or scar tissue.
Electrical stimulation should not be performed on people with pacemakers, or during pregnancy. Please advise your practitioner of any metal prosthesis.
Application of heat or cold has the risk of frostbite or burns. Deep tissue massage and mobilization has the potential to cause cause bruising, dislocation, and muscle tears. Let your therapist know when enough is enough.
The decision to accept a specific therapy is a complex process. Considerations include: the harm from the natural progression of a disease if left untreated, the potential harm from a failed therapy, and the potential benefit from a successful therapy. Notice to Pregnant Women: Al female patients must alert the doctor if they know or suspect that they
are pregnant, since some of the therapies used may present a risk to the pregnancy.
I understand that I may ask questions regarding my treatment before signing this form and that I am free to withdraw my consent and to discontinue participation in these procedures at any time. With this knowledge, I voluntarily consent to the above procedures, realizing that no guarantees have been given to me by the Physical Medicine Group regarding cure or improvement of my condition.
Signature of Patient’s Parent/Guardian, on behalf of minorPage 3 of 5 Registration package Physical Medicine Group 2010 Privacy Practices
In 1996, the Health Insurance Portability and Accountability Act (HIPAA) was passed into law. The primary goal of this federal legislation was to make it easier for people to maintain basic health insurance benefits and help the health care industry control administrative costs. One portion of this act contains rules for protecting the privacy of your health information. Health care facilities were to be in compliance with this portion of the law by April 14, 2003. Protection of your health information is not new to health care organizations in Washington State and Physical Medicine Group has always been committed to protecting your privacy. However, this federal law does strengthen protection of your privacy and gives you more control over the use and disclosure of your health information.
The HIPAA regulation gives Physical Medicine Group the right to use and disclose your health information for treatment, payment, and certain health care operations purposes without specific authorization from you. In addition, it grants you six specific rights regarding your health information: 1. Right to request access to or a copy of your health information. We will ask that you make your request specific and in writing. We may charge a reasonable fee for the cost of producing and mailing the copies. In certain situations, we may deny your request and wil tel you why we are denying it. In some cases, you may have the right to ask for a review of our denial.
2. Right to request an amendment to your health information if you believe our records are incomplete or inaccurate. Your request for amendment must be in writing and provide the reason for your request. In certain cases, we may deny your request. If so, we wil notify you in writing. You may respond by filing a written statement of disagreement with us and ask that the statement be included with your health information.
3. Right to request restrictions by asking that we limit the way we use or disclose your medical information for treatment, payment, or health care operations. You may also ask that we limit the information that we give to someone who is involved in your care, such as a family member or friend. We are not required to agree to your request. If we do agree, we wil honor your restriction unless it is an emergency. We may ask you to make your request in writing.
4. Right to request that we communicate with you by another means to preserve confidentiality. For example, if you want us to communicate with you at a different address or telephone number we can usual y accommodate your request if it is reasonable.
5. Right to seek an accounting of certain disclosures by asking us in writing for a list of the disclosures we have made of your health information, except for disclosures for treatment, payment, health care operations, information provided to you, facility directory listings, certain government functions, and disclosures made prior to April 14, 2003. 6. Right to receive a paper copy of our Notice of Privacy Practices. We wil offer you a copy of our notice the first time you register or present for treatment or health care services at Physical Medicine Group. You may also request a copy of this notice at any time or obtain a copy on our website. This notice lists al the different ways that we might use or disclose your health information and provides you with information about exercising your various rights.
Physical Medicine Group respects your rights and we will continue to do our best to protect your privacy and the privacy of your health information.
Signing acknowledges receipt of this information.
Signature of Patient’s Parent/Guardian, on Page 4 of 5 Registration package Physical Medicine Group 2010 Patient Feedback Policy
Do you have a compliment or a complaint? You can phone us, send us an email, or send a letter. You can discuss your issue with our staff in private, at no cost. We also have an independent Naturopathic Physician with whom you can contact if you are uncomfortable discussing an issue with our staff. Your opinion matters.
Cancellation, and Late Arrival Policy
If you are going to be late for an appointment, please cal at your earliest convenience. If you need to cancel an appointment, please give our office a 24 hour notice. Missed appointments without proper notification are subject to a $100 missed appointment charge. The clinic reserves the right to terminate a provider and patient relationship for habitual missed appointments without proper notification.
Page 5 of 5 Registration package Physical Medicine Group 2010


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