Russo Chiropractic Corporation

12362 Euclid St.

• Garden Grove, Ca. 92840
Phone (714) 534-5712 Fax (714) 534-3581

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m= have BOT14 your insurance card and your armees ?cense present and a,aiiab1efar copy at Y Ttrst appoi'ent)

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NAME:

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REFERRED TO THIS OFFICE BY • -

PRESENT COMPLAINT

DATE OF INJURY IS THIS WORK RELATED?

155THIIS AUTO RELATED?

P'ease note atwe bIll your insurance company as a courtesy only. The responsFWity of payment is
yours in event that jour insurance company fails to make trneiy and/or proper payment Paents are
responsbible for arty items issued ard not covered by the insurance company and for the copays
and deductibles.
Vqlth my signature hereby state that all of the above iion was truthful and rate I have read
and fully understand the abce information.

SIGNED • DA
'l=
 RUSSO CHIROPRACTIC CORP.
12362 EUCLID ST.
GARDEN GROVE, CA. 92840
P (714) 534-5712 F (714) 534-3581

Dr. Michael Russo, D.C., Q.M.E.

ASSIGNMENT AND INSTRUCTION FOR DIRECT PAYMENT TO DOCTOR

PRIVATE AND GROUP, ACCIDENT AND HEALTH
RE:
PATIENT:
EMPLOYER:
OLAIM/GROUP#:
SS#flD#:

I hereby instruct and direct the Insurance Company

To pay by check made out and mailed directly to:

c/c:
Russo Chiropractic Corp.
12362 Euclid Street
Garden Grove, CA 92840

The professional or medical expense benefits allowable and otherwise payable to

me under my current insurance policy as payment toward the total charges for
professional services rendered. THIS IS A DIRECT ASSIGNMENT OF MY
RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed
my indebtedness to the above-mentioned assignee, and 1 have agreed to pay, in
a current manner, any balance of said professional service charges over and
above this insurance payment.

A photocopy of this Assignment shall be considered as effective and valid as the

original.

I also authorize the release of any information pertinent to my case to any

insurance company, adjuster, or attorney involved in this case.

Dated at Garden Grove, CA this day of 20_.

Signature of Claimant Witness

 *OlD CONSENT*
PATIENTS REQUEST FOR CHIROPRACTIC AND/OR PHYSIOTHERAPY CARE
Dear Patient, we would like to personally welcome you to our clinic. This notice is to advise you that
every type of health care delivery system, including chiropractic care, has some associated risks and the
potential for occasional problems of some kind. These problems can include temporary soreness, sprain
sam, bruising, burns, fractures, dislocations, disc injuries, stroke, etc. In considering these issues,
remember that humans and their injuries are unique, and treatment that might be very effective for one
person might not be as effective for another person. While we are committed to providing you with the
best and safest treatment possible, we also have a legal responsibility to advise you about some very rare
but potential problems that can occur with chiropractic care and/or physiotherapy. Before you start your
treatment, you need to review this information which is called your "informed
consent." No treatment can begin until you have reviewed, this document authorizing treatment
based on your informed consent Please feel free to discuss any questions or concerns that you may
have directly with the Doctor before any treatment at our office.
Remember, we always have time to talk with you about any concerns or questions.
Disc Herniations: Non-surcal disc injury problems are frequently and
successfully treated by skilled chiropractors. Occasionally, chiropractic
treatment may aggravate a preesting disc problem. Very rarely, chiropractic
care may cause a disc problem to flare-up or even worsen, especially if the disc
is already severely damaged before treatment began.
Soft Tissue Injury This ter= refers to injured muscles; tendons;
ligaments; cartilage (and their attachments to bone); blood vessels; and nerves.
At r4-es, these tissues (or scar tissue) may be stretched, resulting in temporary
pain.
Rib Fractures: Rarely, chiropractic adjustments may crack a rib bone.
This risk is increased in the elderly osteoporotic patient. We adjust all of our
patiets ca.refUy, a.rd especiaLuy o'.r older petts to =Irli=iZe this i-islc.
Burns: Some of our physiotherapy equipment and/or modalities (hot
packs, ice, ultrasound, etc.) work by generating heat or cold. Therefore, it is
oossible for a patient to be burned (by heat or ice) if they do not follow
instructions or misuse the equipment. Usually, these are Triior problems but
they can cause temporary redness, some swelling and rild pain for a few days.
Soreness: Chiropractic adjustments, traction, massage, stretching
exercise, etc., all have the possibility of making a patient sore, on a temporary
basis.
Stroke: Stroke from chiropractic care is VERY unconmon. If you have a
history of atherosclerosis, please advise doctor.
Other Problems: There may be problems or complications that might
arise from chiropractic treatment or physiotherapy, other than those described
herein. These "other problems or complications occur so infrequently that it is
not possible to anticipate them, predict them or explain them all in advance of
Starting treatment.
If any problem starts to develop, please advise the doctor.
Disclaimer Chiropractic is a health care delivery system, and as with any health care
delivery system, we do ylot and can not promise or guarantee to cure any specific
thseesc or iidtion.

o ors Signature Patients Signature Today's Date

 Russo Chiropractic corporation
12362 Ecd St.
Garden Grove, Ca. 284
Phone 714) 5347 1 2 Fax (714) 534-3581.

ACKNOWLEDGEMENT OF RECEIPT OF HiPA NOTICE OF PRlVACY PRACTICES

The following is the privacy oiicy ("Privacy Polic/ of RUSSO CHIROPRACTIC ("Covered "Entity") as
described in the Health insurance Portability and Accouruabilitv Act of 1996 and regulations promulgated there
under. commonly xmov.,n as -JIFAA. HDRA-k rouires Covered Entity by law to maintain the privacy of your
personal health information and to provide you with notice of CoveredEntity's legal duties and privacy policies
wit,i respect to your personal health information. We are required by law to abide by the terms of this Privacy
Noice.

Your Perscivai Health Infor-mation

'We collect oerscnai hcalyth information from you through treatment, payment and re71et4 heaithcare
operation. the appiicahcn and eruioUment process, ath!or healthcare providers or health plans, or tnrcugh other
neans. as aplicabie. Your personal health information that is protected by law broadly includes any information.
oral, written or recordtd, that is created or received by certain :eaith care entities including health care prcviders.
such as physicians and hospitals, as well, as, health insurance companies or plans. The law specifically protects
health information that contains data, such as your name, address, social security number, and others, that couic
be ised to identify you as the individual natient who is associated with that health information.

Uses orD osures of Your Persotal Health Information

Generally, we may not use or disclose your personal health information without your permission.
Further, once your permission has been obtained, we must use or disclose your personal health information in
accordance with the specific terms that permission. The following are the circumstances under which we are
permitted by law to use or disclose your personal health information.

Without Your Consent

Without your consent, we may use or disclose your personal health information in order to provide you
with services and the treatment you require or request, or to collect payment for those services, and to conduct
other related health care operations otherwise permitted or requirri by law. Also, we are permitted to disclose
your personal health information within and among our workforce in order to accomplish these same purposes.
Hcwever. even with your perrdission, we are still required to limit srth uses or disclosures to the minimal emoum
f personal health information that is reasonaniy required to provide those services or complete those activities.

-cmpes of treatment acriv friar inchide: (a) the provision, coordination, or management of health care
arid re12ted services by health care providers; (b) consultation between health care providers relating to a atienr:
or (c) the referral of a patient for health care from one health care provider to another.
Examples of payment activities include: (a) billing and collection activities and related data processing;
(b:: actions by a health plan or insurer to obtain premiums or to determine orfulfill its responsibilities for coverage
and provision of beneflts under its health plan or insurance agreement, determinations of eligibility or coverage,
adudication or subrogation of health benefit claims; (c) medical necessity and appropriateness of care reviews,
utilization review activities; and (d) disclosure to consumer reporting agencies of information relating t
co Uection of premiums or reimbursement

acknowledge that! have read the HIPAA Notice of Privacy Practices.

Signature of Patient or Patient Representative Printed Name

 PRACTICE

PATIENT CONSENT FOR USE AND/OR DISCLOSURE OF PROTECTED HEALTH INFORMATION TO

CARRY OUT TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS

(patient), hereby states that by signing this Consent, I acknowledge and agree as follows:

The Practice's Privacy Notice has been provided tome prior to my signing this Consent. The Privacy
Notice includes a complete description of the uses and/or disclosures of my protected health information
(PHI") necessary for the Practice to provide treatment to me, and also necessary for the Practice to obtain
payment for that treatment and to carry out its' health care operations. The Practice explained to me that the
Privacy Notice is available to me at my request. The Practice has further explained my right to obtain a
copy of the Privacy Notice prior to signing this Consent, and has encouraged me to read the Privacy Notice
carefully prior to my signing this Consent.

2.The Practice reserves the right to change its privacy practices that are described in its Privacy Notice, in
accordance with applicable law.

3.I understand and consent to, the following paragraphs as noted in the Privacy Notice dated _I_
Appointment Reminder; Directory/Sign-In Log; Birthday Cards/Newsletters; Special Events Days; Offic
Protocols; Referral Board; Change of Ownership; Family/Friends.

4.The Practice may use and/or disclose my PHI (which includes information about my health or condition an
the treatment provided to me) in order for the Practice to treat me and obtain payment for that treatment, an
as necessary for the Practice to conduct its specific health care operations.

5.I understand that I have a right to request that the Practice restrict how my PHI is used and/or disclosed to
carry out treatment, payment and/or health care operations. However, the Practice is not required to agree
any restrictions that I have requested. If the Practice agrees to a requested restriction, then the restriction is
binding on the Practice.

6.I understand that this Consent is valid for seven years. I further understand that I have the right to revoke
this Consent, in writing, at any time for allfuture transactions, with the understanding that any such
revocation shall not apply to the extent that the Practice has already taken action in reliance on this consen

7.I understand that if I revoke this consent at any time, the Practice has the right to refuse to treat me.

S. I understand that if I do not sign this Consent evidencing my consent to the uses and disclosures descrid
to me above and contained in the Privacy Notice, then the Practice will not treat me.

I have read and understand the foregoing notice, and all of my questions have been answered to my
full satisfaction in a way that I can understand.

Name of Individual (Printed) Signature of Individual

Signature of Legal Representative Relationship

(e.g.. Attorney-In-Fact. Gll2rdian, Parent if a minor):

Date Signed Witness:

1
 Russo Chiropractic Corporation
12362 Euclid St.
Garden Grove, Ca. 92840
Phone (714) 534-5712 Fax (714) 534-3581

Patent Name Birthdate Sex M/F

Address City
State Zip Phone ( ) Patient Primary Language
Occupation Employer Work Phone
Address City State Zip
Subscriber Name Health Plan
Subscriber ID # Group # Spouse Name
Spouse Employer City State Zip
Primary Care Physician Name PCP Phone
MARK AN X ON THE PICTURE WHERE YOU HAVE PAIN OR OTHER SYMPTOMS.
DESCRIBE YOUR CURRENT PROBLEM AND HOW IT BEGAN:
Li Headache fl Neck Pain F1 Mid-Back Pain 0Low Back Pain
Other
Is this? E Work Related 17 AubRelated 0 N/A A
Date Problem Began
How Problem Bean
Current complaint (how you feel today):.
0 1 2 3 4 5 6 7 8 9 10
No Pain Unbearable Pain
How often are your symptoms present?
(Occasional) [10 — 25% 026 - 50% 051 - 75% El 75— 100% (Constant)
In the past week, how much has your pain interfered with your daily activities (e.g., Work, social activities, or household chores?

No interference 0 1 2 3 4 5 6 7 8 9 10 Unable to carry

In general would you say your overall health right now is: on any activities
D Excellent D.Very. Good 0Good 0Fair D Poor
HAVE YOU HAD SPINAL X-RAYS, MRI, CT SCAN FOR YOUR AREA(S) OF COMPLAINT? 0 No 0Yes
Date(s) taken What areas were taken?
Please check all of the following that apply to you:
0. Alcohol/Drug Dependence Prostate Problems
DD0000DDD

0. Recent Fever Menstrual Problems

Q Diabetes Urinary Problems
Li High Blood Pressure Currently Pregnant, # Weeks
0 Stroke (Date) Abnormal Weight El Gain 0Loss
O CoriucbsteoidUsé (Cortisone, Prëdnisone, etc.) Marked Morning Pain/Sliffliess
0 Taking Birth Control Pills Pain Unrelieved by Position or Rest
0 DiinessfFairithg Pain at Night
0 Numbness in Groin/ButtockS Visual Disturbances
O Cancer/Tumor (Explain) Surgeries

0 Osteoporosis - . 0 Tobacco Use - Type

El Epilepsy/Seizures . Frequeng . . IDay.
El Other Health Problems (Explain) 0 Medications
Family History: 0Cancer 0Diabetes 0High Blood Pressure
0Heart Problems/Stroke 0Rheumatoid Arthritis
I certify to the best of my knowledge, the above information is complete and accurate. If the health plan information
is not accurate, or if I am not eligible to receive a health care benefit through this provider, I understand that 1 am
liable for al charges for services rendeid and I agree to notify this doctor immediately whenever I have changes in
my health condition or health plan coverage in the future. I understand that my chiropractor may need to contact my
physician if my condition needs to be co-managed. Therefore I give authorization to my chiropractor to contact my
physician, if necessary. . . .
Patient Signature . Date