Forms (210) 731-9010 Initial Consultation Form Services > (210) 731-9010 Thank you for submitting your form. We have received your information and will review it shortly. If you have any additional questions or need assistance, please call our office. We look forward to assisting you! 11https://www.spireclinic.com/core/modules/nex-forms-express-wp-form-builderfalsemessagehttps://www.spireclinic.com/ajax-callhttps://www.spireclinic.com/new-patientyes1fadeInfadeOut CONFIDENTIAL PATIENT INFORMATION*First, Middle, Last Name*Phone NumberEmergency Phone*Email*Date of Injury*Date of BirthSocial SecurityCell Phone*AddressCityStateZip CodeEmployerPhone NumberAddressName Of Spouse Or ParentNearest Relative (Other than Spouse)Phone NumberHow Were You Referred To Our Office?.Newspaper .TV .Mail .Sign .FriendOther*SURGERY HISTORYGallbladder, Hernia, Spinal, List Others*MAJOR ILLNESS or PREVIOUS ACCIDENT HISTORYDiabetes, HBP, Heart, List Other, Injuries, Fractures, List others*Are you or is there a possibility you are or may be pregnant?--- Select ---No YesPrimary Health InsuranceAddressCityStateZip CodeGroup No#Phone NumberASSIGNMENT OF BENEFITS/CAUSE OF ACTION/PROCEEDS PAID*Please carefully read and check the boxes below..1. RELEASE OF INFORMATION: You are authorized to release any information you deem appropriate concerning my physical condition to any insurance companies, attorneys, or adjusters, in order to process any claim for reimbursement of charges incurred by me as a result of professional services rendered by you..2. IRREVOCABLE ASSIGNMENT OF RIGHTS & RIGHT OF SUBROGATION: You are assigned the exclusive, irrevocable right to any cause of action that exists in my favor against any insurance company, and/or proceeds paid by any insurance company (including, but not limited to any liability insurance, any health insurance, uninsured/underinsured motorist insurance, personal injury protection insurance, medical benefits insurance, and workers' compensation insurance), individual or entity, for benefits or damages to the extent of your bill for total services if such benefits are owed within the terms of the policy, or damages caused by such individual or entity including the exclusive, irrevocable right to receive payment for such services, make demand in my name for payment, and prosecute and receive penalties, interest, court cost, or other legally compensable amounts owed by an insurance company, or individual or entity, in accordance with the common law, the Texas Insurance Code or other applicable insurance or state statute. I hereby also subrogate my right against all such individuals, entities and insurance companies for benefits or damages to the full extent of your bill for total services. You may take such actions as you deem necessary including the exclusive, irrevocable right to receive payment for such services, make demand in my name for payment, and prosecute and receive penalties, interest, court cost, or other legally compensable amounts owed by an insurance company, or individual or entity, in accordance with the common law, the Texas Insurance Code or other applicable insurance or state statute. I as the patient and/or responsible party, further agree to cooperate, provide information as needed, and appear as needed, wherever to assist in the prosecution of such claims for benefits upon request..3. DEMAND FOR PAYMENT: To any insurance company providing benefits or damages of any kind to me/us for treatment rendered by the doctor/clinic/healthcare provider named above, you are hereby tendered demand to pay in full the bill for services rendered by the doctor/clinic/healthcare provider named above within 60 days following your receipt of such bill for services to the extent such bills are payable under the terms of my/our policy or benefits, or for damages or injuries caused by such entity or individual. This demand specifically conforms with this State's Insurance Code, providing for attorney fees, penalty, court costs, and interest from judgment, upon violation. As relates to payment by Insured/Defendant or his/her liability insurance carrier and/or payment of my current policy, I hereby also direct and instruct same to make out checks to the doctor/clinic/healthcare provider and mail it as follows:PAYABLE TO: San Antonio Spine and RehabMAIL TO: 1313 SE Military Dr. Ste 107 San Antonio, TX 78214.4. THIRD PARTY LIABILITY: If patient's treatments for injuries are the result of the torts of any third party, then the patient(s) and/or responsible party grant a lien and assignment of an interest in my/our cause of action against any right of recovery from such third party to the extent of the bills for treatment, in favor of the doctor/clinic/healthcare provider named above. This lien, assignment and all bills protected thereby, are to be paid in full, at the latest, whenever patient and/or responsible party receives any recovery as a result of the aforesaid torts of such third party, whether the recovery is directly from such third party, from any insurance covering such third party, from any insurance covering patient and/or responsible party (e.g. uninsured/underinsured motorist coverages and personal injury protection/medical payments insurance), or from any other source whatsoever. It is understood and expressly agreed to, that a copy of this assignment may be delivered to the patient and/or responsible party's attorneys, the third party tortfeasor(s), and their insurance companies, the patient and/or responsible party's insurance companies, and any other person whom the doctor/clinic/healthcare provider named above deems appropriate..5. STATUTE OF LIMITATlONS: The patient and/or responsible party hereby agrees that any statute of limitations applicable to any claim of the doctor/clinic/healthcare provider named above shall be tolled from the present until the latter of the final denial of the claim by the insurance company, final decision in the highest level court the claim may be taken to, or the actual discovery by the doctor/clinic/healthcare provider named above, of the receipt of any recovery by patient and/or responsible party as a result of the condition being treated hereunder..6. ATTORNEYS' FEES. COURT COSTS. INTEREST: The patient and/or responsible party hereby agree that if the doctor/clinic/healthcare provider named above has to resort to any collection efforts in order to enforce this assignment and/or collection of any bills due, in addition to the damages sought, the above named doctor/clinic/healthcare provider shall recover all reasonable costs of collection, including but not limited to attorneys' fees and court costs. Additionally, if collection efforts are required, all bills will then incur interest at the rate of twelve percent (12%) per annum, compounded annually, from thirty (30) days after the date the bill was due, until paid..7. UNLIMITED POWER OF ATTORNEY: I hereby grant to the doctor/clinic/healthcare provider named above the power to endorse my name upon any check, drafts, or other negotiable instrument representing payment from any insurance company representing payment for treatment and health care rendered by doctor/clinic/healthcare provider. I agree that my insurance payment representing an amount in excess of the charges for treatment rendered will be credited to my account or forwarded to my address upon request in writing to the doctor/clinic/healthcare provider named above..8. SEVERABILITY: I agree that each and every provision of this Agreement is reasonably necessary for the protection of the rights and interests of San Antonio Spine and Rehab and myself. However, should any provision of this Agreement be found to be invalid, illegal or unenforceable, or for any reason cease to be binding on any party hereto, all other portions and provisions of this Agreement shall, nevertheless, remain in full force and effect.INFORMED CONSENT TO CHIROPRACTIC TREATMENT.I hereby request and consent to the performance of chiropractic adjustments and any other chiropractic procedures, including examination tests, diagnostic x-ray(s) and physical therapy techniques, on me (or on the patient named below for which I am legally responsible) which are recommended by the doctor of chiropractic named below and/or other licensed doctors of chiropractic who now or in the future render treatment to me while employed by, working for or associated with, or serving as back-up for the doctor of chiropractic named below..I understand that, as with any health care procedure, there are certain complications which may arise during a chiropractic adjustment. Those complications include but are not limited to : fractures, disc injuries, dislocations, muscle strain, Horner’s syndrome, diaphragmatic paralysis, cervical myelopathy and costovertebral strains and separations. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. I do not expect the doctor to be able to anticipate all risks and complications and I wish to rely on the doctor to exercise judgement during the course of the procedure(s) which the doctor feels at the time, based upon the facts then known, are in my interest..I have had an opportunity to discuss with the doctor named below and/or with office personnel the nature, purpose and risks of chiropractic adjustments and other recommended procedures and have had my questions answered to my satisfaction. I understand that the results are not guaranteed..I have read ( ) or have had read to me ( ) the above explanation of the chiropractic adjustment and related treatment. By signing below I state that I have weighed the risks involved in undergoing treatment and have myself decided that it is in my best interest to undergo the chiropractic treatment recommended. Having been informed of the risks, I hereby give my consent to that treatment. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.Name(s) and Address(s) of Office or Clinic San Antonio Spine & Rehab1313 SE Military Dr. Ste. 107San Antonio TX 78214 San Antonio Spine & Rehab4242 Woodcock Dr. Ste 100San Antonio, TX. 78228 Print Name(s) of Doctor(s) Treating This PatientDr. Valerie A. Lopez, DCDr. John Raimondo, DCDr. Richard Alexander, DCDr. Sidnie Morris, DCMr. Eugene Benedict LPCCONSENT TO USE PHIAcknowledgement for Consent to Use and Disclosure of Protected Health InformationUse and Disclosure of your Protected Health Information.Your Protected Health Information will be used by San Antonio Spine & Rehab or may be disclosed to others for the purposes of treatment, obtaining payment, or supporting the day-to-day health care operations of this office.Notice of Privacy Practices.You should review the Notice of Privacy Practices for a more complete description of how your Protected Health Information may be used or disclosed. It describes your rights as they concern the limited use of health information, including your demographic information, collected from you and created or received by this office. I have received a copy of the Notice of Patient Privacy Policy.Requesting a Restriction on the Use or Disclosure of Your Information.• You may request a restriction on the use or disclosure of your Protected Health Information..• This office may or may not agree to restrict the use or disclosure of your Protected Health Information..• If we agree to your request, the restriction will be binding with this office. Use or disclosure of protected information in violation of an agreed upon restriction will be a violation of the federal privacy standards.Notice of Treatment in Open or Common Areas.Describe and Notify private areas available upon requestRevocation of Consent.You may revoke this consent to the use and disclosure of your Protected Health Information. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected..I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered to me will be immediately due and payable..I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case. DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE.*Signature of Patient Submit
