Miniaci Chiropractic Acupuncture Center LLC53 High StreetEast Haven - PDF document

1 Miniaci _Chiropractic & Acupuncture Cent
Miniaci _Chiropractic & Acupuncture Center, LLC53 High Street-East Haven, CT 06512203-469-5210PATIENT INFORMATIONNAME:ADDRESS:CITY:STATE:SOCIAL SECURIW #:DATE OF BIRTH:HOME PHONE:E-mail:Employer:Emergency Contact:phone:MARITAL STATUS:FIRSTMiddleLASTzip:sEX: (M)_ (F)_(Month, Day, year)_Work Phone:Ext_Cellular:Relation:(Single)_ (Maried)_(Widowed)_ (Divorced)_NAME:SOCIAL SECURITY #:EMPLOYER:HEALTH INSURANCE:INSURANCE INFORMATIONFIRSTMiddleLASTDate of Birth:Work Phone:AND / ORProvider:Policy #:Claim #:lnsured Name:LIABILITY INSURANGE:AND / ORProvider:Claim #:Claim Adjuster Name/phone #lnsured Name:AfiORNEY:Name:Address:PLEASE GIVE US YOUR HEALTH INSURANCE CARDSSO WE CAN MAKE A COPY FOR OUR FILES. Miniaci Ghiropractic & Acupuncture Genter, LLC53 High Street-East Haven, CT 06512203-469-5210lnjury lnformationPlease answer all questions completelyt!Name:Date of injury:Where did the injury occuP (name and addressTime of injury:-am/pmDescribed what happended:List the extent of the injuries as you know them:Where did you feel pain immediately after the accident?Where were you taken after the accident:Hospitalized?[]YesINolf yes, Admitted [] Yes I No How long?.Name of hospital:Name of Doctors:Treatment rendered:Diagnosis:How often did you see the doctor?How long did you see the doctor?Have you ever had any complaints in the involved area before? [ yes [] Nolf yes, what were the complaints?Prior to this injury were you capable of working on an equal basis with others your age [] yes [] NoAre you work activities restricted as a result of this accident? [] yes I Nosince this injury are your symptoms I improving [] getting worse [] same MINIACI CHIROPMCTIC & ACUPUNCTURE CENTER, LLC53 High Street, East Haven, CT 06512Phone: 203469-521 0 Fax: 203-468-g59gCURRENT COMPLAINTS / PAIN RATINGSPATIENT NAME:Today's Date:HEADACHEThe PAIN is:_coNSTANT-INTERMITTENT_occAsIONAL_oN THE RtcHT-ON THE LEFT_oN BOTH STDESThe SEVERTTY is:_MtLD_MODERATE-SEVERETRIGGERED BY:-SMELLLIGHTlwould DESCRIBE it as:-PULL -SHARP_POUNDING _STAB_PULSATTNG _THROB-PRESSURE_NAUSEA _|NSOMN|A_v

2 oMtTtNG _DtzztNEssHOW SOON AFTER THEACCI
oMtTtNG _DtzztNEssHOW SOON AFTER THEACCIDENT DID THISSYMPTOM OCCUR?_lmmediately_ days afterThe PAIN is: The SEVERTTY is;_CoNSTANT _MILD_|NTERMITTENT. _MODERATE_occAStoNAL SEVERE-ONTHE RIGHT :-ON THE LEFT_oN BOTH SIDESI would DESCRIBE it as:-ACHE_BURNtNG-DULL-NUMB_PINS & NEEDLES_RADIAT|NG-SHARP_soRE_STABBtNG-STIFF-TENDER_THROBHOW SOON AFTER THEACCIDENT DID THISSYMPTOM OCCUR?_lmmediately_ days after_CoNSTANT _MILD_|NTERMITTENT _MODERATE_occAslONAL _SEVERE_oN THE RtcHT-ON THE LEFT_oN BOTH STDESIwould DESGRTBE it as:_ACHE _SHARP_BURNTNG sone_DULL '-srnaetrue_NUMB.. Jlrr_P|NS & NEEDLES ]reNorn-MDIATING IHNOEHOW SOON AFTER THEACCIDENT DID THISSYMPTOM OCCUR?_lmmediately-days afterTne PAIN Is: Tne SEVERTTY Is:_CoNSTANT _MILD_|NTERMITTENT _MODEMTEj_occAstoNAL _SEVERE__oN THE RIGHT-ON THE LEFT_oN BOTH STDESIwout.o DESCRIBE ITAS:.-ACHE. BURNING-DULL-NUMB& NEEDLES_RADtAtNG-SHARP_soRE_STABB|NG.-TENDER-THROBHOW SOON AFTER THEACGIDENT DID THISSYMPTOM OCCUR?'lmmediately_ days afteroTHER AREA (EX.: RtcHT FOREARM, LEFI CALF)THE PAIN E: THe SEVERITY Is:_CoNSTANT MILD_|NTERM|TTENT -MODEMTE_occAstoNAL -SEVERE_oN THE RtcHT-ON THE LEFT_oN BOTH SIDESlwoulo DESCRIBE nes:-ACHE_BURNtNGDULL-NUMB_PINS & NEEDLES_RAD|AT|NGHOW SOON AFTER THEACGIDENT DID THISSYMPTOM OCCUR?_lmmediately_ days after M IN IACI CHIROPRA9TI g I AqUPUNCTURE CENTER, LLC53 High Street, East ff"u"n_Ci oosf zphone: 203-469_5210 raxiog46g-g5g8. CURRENT COII,IPI.AINTS I]Pruru RATINGS(coNTtNUED)How are you sleeptng?What Activlfles Relleve your pain:_Applying a Heating pad_.,Applying lce-Applying Moist Heat_Chiropractic TreatmentLying Down.-over-the-countdr Medications-Prescription Medications_Resting,Job activitiesLifting_Reading_Running-school activities_SittingSitting-stretching_Watking_Other_Standing-Tuming_Twisting.Using ComputerUsing Telephone_Walking.What Activities tncrease your paln:Bending_Caring fqr my kids-Going Up /.Down Stairs_Kneeling_Lying DownExercise_Other (describe)My symptoms and paln are:_Worse in the Moining_Worse in the Evening_Constant all Daylntermittent all DayAre You Worklng?

3 :-YES lf yES, how many hours perweek:. A
:-YES lf yES, how many hours perweek:. Are you tolerating your generalwork tasks:_NOlf NO, Explain: Miniaci Chiropractic & Acupuncture Center, LLC53 High Street-East Havdn, CT 06512203-469-5210MEDICAL HISTORYPatient Name:Habits:Today's Date:Smoke: _Never _Occasional _HeavyAlcohol: _Never _Occasional _HeavyPast Medical History (include dates)SurgeriesFracturesSerious lllnessWor:ke/s Comp lnjuriesPersonal lnjuriesSport or other injuries to head, neck, or back ,Do you have any health problems not tisted above?Have you been treated for any health condition in the past year?'Are your currently taking any medicaticins?Any prior history of your current complaints:Have you been treated by another medical doctor or chiropractor for this ailment? yES NOlf yes, what is the doctor's name?Describe the type of treatment you are / were receiving:Diagnosis of previous physician:Length of time under care:Results:Family Physician :Address:Date of last physical:May we provide him/her with copies of your reports: [] yes I no WLAST NAME:lNlTlAL EVALUATION - Slip and Fall AccidentFIRST NAME:MI:Date:What brings you into our office?When did this accident happen?lmmediately after the accident, did you feel dazed? tr YesDid you lose consciousness?Was your head injured?lmmediately after the accident, did you experience:Did you see another doctor before coming here?Did you goto a hospital after the accident?trNoDNOuNotr Neck Pain tr Low Back PaintrNoEISlip and Fall Accidentn Yes n No lf yes, which hospital?How did you get to the hospital?tr Ambulance tr Droveself tr Somebody else tr PoliceWere any of the following tests performed at the hospital?tr X-Raystr MRIn CTScan tr Labworktr Staying the same n Getting worsetr Yestr Yestr Headachetr Yestr YeSEl Yestr Weaknesstr Yestr YesO YestrNooNoD StresstrNotrNotrNoDo you feel your condition is: o lmprovingHave you lost time from work?Can you perform physical work activities?lf no, because of: tr PainCan you go to sleep without problems?Do you awaken because of pain?Did you have sleep problems before?Activities of Daily Liv

4 ino Please select all activities which y
ino Please select all activities which you are currently experiencing problems:tr Seeingtr Tastingtr Smelling tr Eatingtr Hearingtr lnsomniatr Dressing tr Readingtr Standing tr Leaningtr Typingtr writingn Grasping tr Using the toilettr Walking tr Stooping tr Squatting El Loss of sexual drivetr Bendingtr Sittingtrl Twistingtr Drivingtr Carrying tr Liftingtr Pushingtr Restful sleepingD Sportstr Exercising o Reclining El Loss of concentrationtr lrritable C Riding in car tr Air travel tr Climbing tr Pullingtr Grooming O Pinchingtr Kneeling n Reaching E Nervoustr Bathingtr Holdingtr Changes in personalitytr Tactile feelingPage 1 of3 Past Medical History Please select all conditions that you have had or are currently having:o None o Other o Abdominal pain o Weight Gain/loss o Anginao Anorexia o Anxiety o Aortic aneurysm o Arthritis o Asthmao Bladder infection o Blood disorder o Breast lumps tr Breast soreness o Bronchitiso Cancero Colitiso Dermatitis,Eczema o Diabetes,/ Rashu Endometriosis o Epilepsyo General fatigue o Goutswallowingo Excessive thirst o Faintingo Depressiono Emphysemao Frequent urinationo Cardiovascular Dx o Chest pain o Chronic cough o Chronic Sinusitiso Constipation tr Convulsions o COPDo Difficultyo Dizzinesso Hand pain o Headache o Heart attacko Heart disease o Heartburn / o Hepatitis o HBP o High cholesterollndigestiono High PSA o High triglycerides o Hypertension o lrregular menstrual o lrritable colonflowo Jaw pain o Kidney disorders o Kidney stones o Liver/Gallbladder o Loss of appetiteproblemss Loss of bladder o Low back pain o Lung disease o Mental disease o Mid back paincontrolo Muscular o Neck pain o Osteoarthritis o Pain in ankle or o Pain in lower legcoordination foot or kneeo Pain in upper arm tr Pain in upper leg o Painful urination o PMS o Pneumoniaor elbow and hipo profuse menstrual o Prostate problems o Rapid heartbeat n Renal Dx o Rheumatoid,ow arthritiso Scoliosis o Shoulder pain o Stroke o Swelling./stiffness o Thyroid diseaseof jointso Tinnitus/ o Tuberculosis o Tumor o Ulcer a Visual disturbancesear nois

5 eso Wrist painPage 2 of3 Familv Historv
eso Wrist painPage 2 of3 Familv Historv Please select all conditions that run in your f,amily:o None o Other a Abdominal pain o Weight Gain./loss o Anginao Anorexia o Anxietyo Aortic aneurysm o Arthritis o Asthmao Bladder infection o Blood disorder o Breast lumps o Breast soreness r: Bronchitiso Canceru Colitiso Cardiovascular Dx o Chest pain o Chronic cough o Chronic Sinusitiso Constipation tr Convulsions o COPDo Depressiono Dermatitis,Eczema s Diabetes o Difficulty o Dizziness o Emphysema/ Rash swallowingo Endometriosis o Epilepsy o Excessive thirst o Fainting o Frequent urinationo General fatigue o Gouto Hand pain o Headache o Heart attacko Heart disease o Heartburn / o Hepatitis o HBP o High cholesterollndigestiono High PSA o High triglycerides o Hypertension o lrregular menstrual o lrritable colonflowo Jaw pain o Kidney disorders o Kidney stones o Liver/Gallbladder o Loss of appetiteproblemso Loss of bladder o Low back pain o Lung disease o Mental disease o Mid back paincontrolo Muscular o Neckpain o Osteoarthritis s Pain in ankle or o pain in lower legcoordination foot or kneeo Pain in upper arm tr Pain in upper leg o Painful urination o PMS o Pneumoniaor elbow and hipo Profuse menstrual o Prostate problems o Rapid heartbeat o Renal Dx o Rheumatoidflow arthritiso Scoliosis o Shoulder pain o Stroke o Swelling./stiffiess o Thyroid diseaseof j ointso Tinnitus/ o Tuberculosis o Tumor o Ulcer o Visual disturbancesear noiseso Wrist painPage 3 of3 Suroical History Please select all surgeries that you have had in the past.tr None E: Other C: Abdominal tr Abdominoplasty tr AbortionExplorationtr ACL A Adenoid Removal tr Angioplasry El Appendectomy El Bone FractureReconstruction RePairtr Breast Lump tr Bunion Removal tr Carotid Artery tr Cataract Surgery n Cervical SpineRemoval Surgery Surgeryn Cholecystectomy tr Cosmetic Breast tr C-Section tr Facelift tr GallbladderSurgery Removaln Gastric Bypass o Heart Bypass Surgery tr Heart Surgery n Hemorrhoid tr Hernia RepairSurgeryD Hip Joint tr Hysterectomy tr Kidney n Knee fl Knee JointReplacement T

6 ransplant Arthroscopy Replacementtr Knee
ransplant Arthroscopy Replacementtr Knee Surgery D LASIK Eye Surgery tr Liposuction tr LumbarSpine tr MastectomySurgeryn Prostate tr Rotator Cuff Surgery tr TMJ Surgery u Tonsillectomy tr VasectomyRemovaltr Surgical History was reviewed:Not contributoryMedications Please select all medications that you are currently taking:o None n Other o Analgesics tr Antacids o Antibioticso Antihistamines o Anti-lnflammatory o Arthritis o Aspirin o Birth Controlo Blood Pressure n Bone Density o Cancer o Cholesterol o Daily Vitaminso Diabetes o Digestion o Heart o Muscle Relaxerso OTC o Pain o Steroids o ThyroidAlleroies Please select all items that you are allergic tolo None s Chemical o Environmentala Food o Medication o Seasonal o OtherSocial HiStory Please answer the following questions:n Married n Single n Widowed n Divorced n SeparatedDo you have any children? tr Yes tr No lf yes, how many?Doyou use: tr Tobacco tr Alcohol tr CoffeePage 4 of3 Miniaci Chiropractic & Acupunchtre Center, LLC - 5 3 High St - East Haven CT 065 I 2INFORME CONSENT TO CHIROPRACTICADJUSTMENTS AND CAREI of. . ftqym)D ative non-invasive teatment to the joints and soft tissues- Irmderstand that thl procedur". rrr"y consist of manipulation/adjustnents involving movement of the joints and soft -tissues. physical tfrlrapy modalities and exercises may also be used. Although spinal manipulation is considered to bea safe ard effective form of therapy for muscuioskeletal problems, I am aware that there are possible risks andcomplications associated with manipulation and therapy procedures as follows:Chiropractic care is the science, philosophy and art of locating and correcting spinal subluxations (misalignments) and* ,r&, is oriented toward impiovemeni olspinal function relative to range of motion, muscular and neurologicalaspece. There has been no promise, implied br otherwise, of a cure for arry symptom, disease or condition as a resultof teatuent in this office- As with the iractice of medicine, the practice of chiropractic is not an exact science, butrelies upon infonnation rela

7 ted by the patieng information gathered
ted by the patieng information gathered during examination, and the doctor's interpretationthereof, as well as the doctor's judgement and �epertise in working with like cases- It is not reasonable to elPect mychiropractor to be able to anticipate, or elplain, all possible risks and complications of a given procedure on anypartiiular visit and I wish to rely on the doctor to exercise professionaljudgment during the course ofany procedures,which he feels at the time to be in my best interest. Al undesirable resulq or side effec! does not necessarily indicateerror in judgment or an improper keatnent.I underctard that the chLopractor will use his/her hands or a mechanical device upon my body to a joint which maycause an audible "pop" ori'clicld'. As with any health care procedure there are certain complicatious which may ariseduring a chiropractiJadjustment. Those complications include sprains/stains, soreness, dizziness, nause4 dislocations,fractures, disc injuries, or cerebral-vascular accidents (stoke)- These complications are extremely rare occlllrences.Rare complications of physical therapy keafinents may include burns and or skin irritation/rednes's.Reasonable alternatives to chiropractic care may include: over the counter analgesics, rest medical care andprescription medication including pain medicine, anti-inflammatory, & muscle relaxers, or possibly surgery.I hereby request and consent to the performance of chiropractic adjustments and other procedures by Dr. Miniaciand/or othei licensed doctors of chiropractic who now or in the future may practice in, work or associate with, or beemployedby Miniaci Chiropractic & Acupuncture LLC.I have read the above consent, or had it read to me, have made my decision voluntarily and freely. To attest to myconsent to these procedures I hereby affix my signature to this authorization for teatrnent.IVlPa\ient's Signatr:reDatePatieut's Name PrintedWihess:datePatient Questions/Comments:COMPLETE FOLLOWING IF PATIENT IS A MINOR ORI]-NABLE TO CONSENT:Patient name:Age:Name of person legally authoriz

8 ed to sign for patient:Relationship:Sign
ed to sign for patient:Relationship:Signature of authorized Person:Date:20l jconsentform.doc Miniaci Chiropractic & Acupuncture Center, L.L.C-53 High StreetEast Ifaven, CT 06512By affixing my signature below, I am indicating that I understand and agreeto the following policies of Miniaci Chiropractic & Acupuncture Center:Health and accident policies are an agreement between an insurancecarrier and myself. The chiropractic office will assist me in the completion ofany forms needed to assist me in collection from the insurance carrier, however,any fee for service is ultimately my responsibility. The chiropractic office willcheck my chiropractic benefits for me, however benefit verification is never aguarantee of either payment or coverage, and it is ultimately my responsibility toknow my coverage/policy. Should my insurance carrier require a referral of anytype, I am responsible for obtaining the referral as well as for making sure thatthe chiropractic office has received the referral; further, I am responsible formaking sure that updated referrals, if needed, are provided to the chiropracticoffice in a timely manner. lf I fail to verify a referral or, should a referral not bepresent at the time of the service, I am accepting full flnancial liability for servicerendered. I further acknowledge that my insurance carrier may not ofter a benefitsufficient to cover all of the visits needed, or that they may disallow certainservices for which I will be responsible. Co-pays, coinsurance and deductiblesare due at the time of service. Acceptable methods of payment are: cash,personal check, money order, debiUATM cards, Visa, MasterCard, AmericanExpress, and Discover Card; co-pays not paid at the time of service aresubject to a $10.00 per billing cycle fee.There is a $25.00 fee for appointments not cancelled with 24 hournotification. There is a $25.00 returned check fee regardless if it can heredeposited.I have been advised that the office will protect my personal healthinformation in accordance with the HIPA,A laws. I further acknowledge thatI may re

9 ceive a written copy of the office's HIP
ceive a written copy of the office's HIPAA practices at any time, andthat I acknowledge that my information, at times, will be shared with various otherentities including but not limited to physicians, specialists, and insurance carriersfor the purpose of coordinating care and collecting account balances.My signature below further indicates: I authorize the release of any medical orother information necessary to process my claims/bills. I also requestpayment of government benefits either to myself or the party who acceptsassignment . I authorize payment of medical benefits to: Keith A. Miniaci,D.C., Mipiaci Chiropractic & Acupuncture Center LLC..2017.docDate: MINIACI CHIROPRACTIC & ACUPUNCTURE CENTER, LLC53 High Street, East Haven, CT 06512Phone: 203-469-5210 Fax 203-468-8598ATTORNEY LIENDate:To:AttorneyRE:File #I hereby authorize and direct you, my attorney, to pay directly to said doctor such sums as may be due andowing him for professional services rendered to me both by reason of this accident and by reason of any otherbills that are due his office and to withhold such sums from any settlement, judgment or verdict as may benecessary to adequately protect said doctor. I hereby further give a lien on my case to said doctor against anyand all proceeds of any settlement, judgment or verdict which may be paid to you, my attorney, or myself asthe result of the injuries for which I have been treated.lf there is any Med Pay from Auto lnsurance and/or Health lnsurance, said Doctor will submit for payment andagree that any non-paid services will be put to settlement. (lE: Deductibles, Co-Pay, etc.)I fully understand that I am directly and fully responsible to said doctor for all professional bills submitted byhim for service rendered to me and that this agreement is made solely for said doctor's additional protectionand in consideration of his awaiting payment; I further understand that such payment is not contingent on anysettlement, judgment or verdict by which I may eventually recover said fee. I further agree to waive theapplicable statute

10 of limitations with regard to collection
of limitations with regard to collection of this debt so that the provider may proceed legally tocollect this debt in the event you, my attorney, are unsuccessful in obtaining money damages for me.I further direct you, my attorney, to pro-mptly notify the doctor's office upon any of the following events:Settlement of claim for legal damages, entry of judgement by stipulation or after trial, dismissal or withdrawalof claim, transfer of the claim or any part thereof to other counsel.Dated:SIGNATURE:Street:State, Zip:.The undersigned being attorney of record for the above patient does hereby agree to observe all the terms ofthe above and agrees to withhold such sums from any settlement, judgment or verdict as may be necessary toadequately protect the said doctor named above.Dated: ....,.........j.. Attorney's Signature:Please sign, date, and return original to doctor's office.Keep copy for your records.Attorney: Miniaci Chiropractic & Acupuncture Genter, l-LG53 High Street-East Haven, CT 00512203-469-521.OAUTEORIZ.A'TION TO OBTAIN AND/OR DISCLOSE EEALTE INT'ORMATIONI hereby authorizeto disclose andlor obtain my individually identifiablehealth information as described her to the person/.organization named below. I understand that this authorization isvoluntary and that it may include information relating to AIDS, HlV, infection, behavioral health services, psychiatriccare, treatment for alcohol and/or drug abuse.Patient name: DOB:lnformation to be disclosed/obtained:Service dates:[] lnitial evaluation/examination I Emergency room records [] Daily Treatpnent notesI lntake paperwork[] Consultation reports[] Laboratory tests/resultsI Radiology fi Ims/reportsI Entire record (Consideration will be given in releasing entire record only when a subsection to the record will not servethe intended purpose of this disclosure.)[] Other (SpeciDO NOT release the following information:Name of person(s) /organization(s) to whom the disclosure is to be made orfrom whom the information is to beobtained:I am requesting the information be disclosed for the purpo

11 se of: (for example: legal reasons, cont
se of: (for example: legal reasons, continued care,insurance, another medical opinion, Worke/s compensation, Employment, research, personal usage, SocialSecurity):I understand this authorization may be revoked lN WRITING at any time except to the e{ent that the action has alreadybeen taken in reliance on this authorization. This authorization shall automatically expire in 1 year from the date ofsignature unless otherwise specified in the space provided here: EXPIRATION DATE:I understand I may inspect and copy the information to be used and disclosed under this authorization and that I mayreceive a copy of this signed authorization form. There may be a fee associated with copying, not to exceed what isallowed by Connecticut State Law (45 cents per page, plus the cost, if any, of postage).The facility, its employees, olficers, and physicians are hereby released from any legal responsibility or liability fordisclosure of the information listed to the extent indicated and authorized herein.I understand that this provider may not con$ition treatment on the provision of this authorization except in cases ofresearch related treatment protocols or studies being conducted by outside third parties through this provider. ln suchcases specific authorization for the research related treatment protocols /studies will be signed as a condition ofparticipation.NOTICE TO RECIPIENTS: As the recipient of Jhis information you may use the information only for the stated purpose.You may disclose this information to another party ONILY :. With written authorization from the patient or his or her legal reprebentative;. As required by state and or federal law. lf needed for the patienfs continued careIf this disclosure contains information regarding EfV behavioral health, psychiatric, alcohol or drug abuse educationtraining, treatment rehabilitation or research the following shall apply:This inforrration has been disclosed to you from records whose contrdentiality is protected by federal law. Federal regulations prohibityou from making any firrther disclosure of i

12 t without the specific written consent o
t without the specific written consent of the person to whom it pertains, or as otherwisepermitted by such regulations. A general authorization for the release of medical or other information is not sufiicient for this pulpose.NOTICE TO THE INDTYIDUAL REQT]ESTING DIS CLOSI]RE :Your signature below indicates that you understand that if the organization authorized to receive the information is not ahealth care provider or health plan and the information disclosed is NOT protected by definition under current laws, then thereleased information may no longer,be protected. by the EIPAA Federal Privacy Regulations.Patieut/legal representative sign Miniaci Chiropractic & .Acupuncture Genter, LLC53 High Street-East Haven, CT 06512203-469-5210AUTHORIZATION TO OBTAIN AND/OR DISCLOSE HEALTH INF'ORMATIONhealth information as described herto the person/organization named below. I understand thatihis authorization isvoluntary and that it may include information relating to AIDS, HlV, infection, behavioral health services, psychiatriccare, treatment for atcohol and/or drug abuse.Patient name:DOB:lnformation to be disclosed/obtained:Service dates:I lnitial evaluation/examination I Emergency room recordsI Daily Treatment notesI lntake paperurork[] Consultation reports[] Laboratory tests/resultsI Radiology fi lms/reports[] Entire record (Consideration will be given in releasing entire record only when a subsection to the record will not servethe intended purpose of this disclosure.)I Other (Specify):DO NOT release the following information:Name of person(s) /organization(s) to whom the disclosure is to be made or from whom the information is to beobtained:I am requesting the information be disclosed for the purpose of: (for example: Iegal reasons, continued care,insurance, another medical opinion, Worker's compensation, Employment, research, personal usage, SocialSecurity):I understand this authorization may be revoked lN WRITING at any time except to the extent that the action has alreadybeen taken in reliance on this authorization. This authorization shal

13 l automatically expire in 1 year from th
l automatically expire in 1 year from the date ofsignature unless otherwise specified in the space provided here: EXPIRATION DATE:I understand I may inspect and copy the information to be used and disclosed under this authorization and that I mayreceive a copy of this signed authorization form. There may be a fee associated with copying, not to exceed what isallowed by Connecticut State Law (45 cents per page, plus the cost, if any, of postage).The facility, its employees, officers, and physicians are hereby released from any legal responsibility or liability fordisclosure of the information listed to the extent indicated and authorized herein.I understand that this provider may not condition treatment on the provision of this authorization except in cases ofresearch related treatment protocols or studies being conducted by outside third parties through this provider. ln suchcases specific authorization for the research related treatment protocols /studies will be signed as a condition ofparticipation.NOTICE TO RECIPENTS: As the recipient of lhis information you may use the information only for the stated purpose.You may disclose this information to another party ONLY :. With written authorization from the patient or his or her legal representative;. As required by state and or federal law. If needed for the patient's continued careIf this disclosure contains information regarding EfV behavioral health, psychiatric, alcohol or drug abuse educationtrainiug, treatment rehabilitation or research the following shall apply:This information has been disclosed to you from records whose confideutiality is protected by federal law. Federal regulations prohibityou from making any firrther disclosure of it without the specific written consent of the person to whom it pertains, or as otherwisepermitted by such regulations. A general authorization for the release of medical or other information is not sufiicient for this purpose.NOTICE TO THE INDTYIDUAI PSQIIESTING DIS CLOSURE :Your signature below indicates that you uuderstand that if the organizatio

14 n authorized to receive the information
n authorized to receive the information is not ahealth care provider or health plan and the information disclosed is NOT protected by definition under current laws, then thereleased information may no longer b,e protected by the HIPAA Federal Privacy Regulations.PatientAegal representative signDate: Miniaci Chiropractic & Acupuncture Center LLC53 High StreetEast Haven CT 0651 2203-4G9-521 0 fax: 203_468_8598It is the policy of this office to collect payment for all services rendered.ln the event that you were involved in a slip and fall accident, the billing is as follows :First: Your own health insurance. Obtaining any necessary refegats or authorizations is theresponsibility of the patient- You should obtain these even if there is a med pay through the propeftyowneds insurance that is paying, for your own protection. Service rendered without a valid referral isthe sole responsibility of the patient.Next: lf you have an attorney, he or she must submit a protection letter to our office, and we willawait payment of any balance until the time that your case setiles; we will hold the balance untilsettlement ONLY with a protection letter, andIiable for anv balance.Finally: lf you are working without an attorney and the liability carrier agrees to accept a lien formfrom our office, we will submit the bills and the lien form tor youl with your signature and we willexpect YOU to keep us updated in a regular fashion with regard to the statui of your claim.The intake packet given on your initial visits contains all of the authorization papers necessary toprocess your billing and have your attorney protect our bill./or have your settiement lien processed.Should you decline to complete all of our forms, you will have to pay cash each visit and await eitherinsurance reimbursement or settlement of your case for reimbursement of fees paid by you; you wilbe given your bill each visit and submission will be your sole responsibility; anicopiesneeded will be charges to you at 45 cents per page.lf there are any questions or concerns, please contact the offi

15 ce manager, Monday through Thursdayfrom
ce manager, Monday through Thursdayfrom 9-5. ."-e- Mi.r,ip-c;. Chi,y-ofi.ra-c:Iip & Ac,oopu*r**u-re, Ce.a:ter LLOfr HiglrusireoiEaal' Hav*t, O-T' O6SLZ-20=-+6q -52iONOfiCE OF ?Ri..i ACT PRACTTCESIEIS NOITCE DESCRTBES EOT[/ MEDICAI EEAIIH INFORMA:IION ASOIIT YOU MAY BE!.SED AND DISCLOSED AND HOTVYOI] CAN GET ACCESS TO TEIS INFORMATON.PLEASE REAI, IT CARE:F"U-I.LY'We are required by Iaw to maiutaia ttr e priwacy of your health idorroatioq to prowid e you ttris detai.edNotice of or:rlegal duties "nr{rFrirracypractices relating to yor:rhealth infor--ojtio:r ior-p*p"*r-"ft'eatmeat, payEoe.at and. health care op era6oas-The foilowing list rrarious ways in vrtrich we lray use or disclose your health info.matioq for purposes oftreatmeof pa5rme,n! and health care operations-tr'or Ireatumt we vd1 use aod disclose yor:r health iaformatiou in proyirring you wiflr teatorent and.seryices aad coordinating yorlr care aad. may disolose informatioo to JtI", provid.ers involved. ia your care-Yourhealthiuformatio:rmayber:sedby d.octors iuvolved inyour care aad byhis assistads as rrell asbyttr'erapists, suppEers of:o.edicar equipueot or ot!.erpvrsous iavorvea io your care- For exa:up1e, we w:l1coatact yourphysiciaa to discuss yourplao ofcare-SorPavmeut %*{T"-auddisoloseyourhEaltl.idorroatiouforbiningaad.palroaentpr:rposes- wemay discLoseyor:rhealttr inf-ormatiorr to yor:rreprese,rtative orto anins:rauce ormaoaged. care co,patry,Medicare, Medicaid, or aoother third party p.yoi- For examplg we-uay contact Medicare or yor:r healthplaa to colfirm yor:r coverage or to request prior approrral for ieardces-that -ai te p*ria"Jtl voo wuuayalso provide iafomralioato collection Jgen* rid"tto*"y. i";th;;"+"se of coll.ectingpaSm.eutunpaid'balaoces owedtlis.g{cemavbepla--ced ooyo*"r"dltruport-*n*r"*vo""i""*'dgyor:rcreditreport would see aar:npaid balaoce with or:r ofEce rryorted-tr'or Eealth care op erations- 'w'e may use or disclose your health information as uecessaqr for h%1thcare operatiols, srch as ',1anage,lae,aq persoa:rel evaluatio4 education aod tainin'g "oato Joo

16 itor or=quzliBr of care' we may disclos.
itor or=quzliBr of care' we may disclos. yor= h.=ltlr. informatiou to "ootl.o ..tty wittr whictr you hawe or had al"h{o*Ft ifttrat eatit5rrequesfs yor:rinfo-.atioufor cerca;o ofits-nea.rur are oper:ations orhealttr carefi-aud aad abuse detection oi "ompli.o"" actirrates-_ For exaople, uJtL tror*"tioa ofmaaypatieots roay.o#*1'"* *u auryzed. forpurpose such as eva}:atiog aoe futr;"idg qualiry of care aaa plaming forfI66',am s -,rflI tu "i.,ti*@ is part ef ss5 lilring record- should you wisb youcansigniawithyourlo''a"'gaod.kstinitialoryor:rnJ*- Furtheritemsaomftisofficesuchasbir.rs,letters' postcards wfll bs rner-led to yor:, at the ad.dress you provide foi ttre pr:rpose for paSm.ent collectiors,ins:rar.ce notificatiou, appointm*t *a -.::"o, ,u*ioarn, etc. we may arso phone you aad leave,oessages at your homg wodg ceit pager voice mafl. ,.g*diog yo* care uaa appointuaents-ILThe following llsts v-arior:s r", U::l,ess you objecg we _ry disclose"r?,,*#"#:1*."H JI'o' otauo- pLJ-. r.* ii".o:ry,Emergeu.cies- 'We may.r:se ,or disclose yor:r heai&. idoEoatiorr as 11eccss^5r ia eorergeaec,lr treat31g.rltsitoatiols, or io tl'e evea. of ttr e po*tiuaity or..-ice �interqtioo if you are consid.ered. at riskAsReqldred'bvlaw' 'weraayuse ordiscloseyor:rheaittr informationv&e,r.required.by1awto do so-Business Associate- w9 ryv aisgrose yourprotected hearttr infornr.atio!.to a cortrastor orbr:sinessassociate who needs tr'e infooratioo to !"rror* su"ices for r:s- o* u-G,'"ss associates are corositted topreserving tLe coltrdeatiality of ttris inforoatioa-Public l[ealth Aetivities- we may disclose yor:rhealth infom.atioa forpublic heartJr activities- Theseactivities mav iucluds {:rynt, t n-o5;q io "prbri" h*rrr. ;;ffi;-for_preveaoting 61 661rq.rinsdisease, iry-r:ry or disabili* reportiug ilaa i*" orneglecr orreportiug birttrs and deatbs-IFwe believe that you have beear a victi. ofabuse' aeelect, ot do-*ti"Goliffiffi. o;d;"4;;;.,=nJa iororraato!. to a.orfy agoveromeat arltority, if atrthorized. bylaw 6r ifyou agree to the reporLEeaith oversieht Activities-

17 'we may disclose yor:r health iofouoati
'we may disclose yor:r health iofouoation to a-health oversight agency foraaivities authorized by ia', scch as u"ait , i"ru"tig.tio*, ir.p;"d;;t ,"*r** acfio:rs or foractivities i*volving govemment oversight ortr" aJltt *" dstJ-' *-wheaenecessa'rto prevstrt a serious threatto yourhealth orsafety ottt"tottl' o@ffiBEc oraoottrerpuooa'*-"yuse or disclosehealtlip3[6mzdo4 lilaiti,g disclosr:res to *-"o-o"'.ile ro help lessen orprlvent the threateaed har,-Judiciar and Administrative Procgedings- wg ma1 disclose your health information in respome to a:ffiH :ffif*i}lT;} 't'o *"v ais"to'"-ioro*"'i.; ;;;*e to a s:bpoena, &."oo.nyLawEuforcemeut Wemaydiscloseyo.urheal6.infonaationforcertaialavreaforceraeatprEposes,iuciudiag for exarapl", to cJmply widrep-orttog r*qri.e-"nts; * **pry -ia a co,rt ordi, *u-a* o,simflarlegalprocess; orto -;; ""rt i";;s;,, d.#;;L;; #:.-*s crimes_Research- wemayuseor-discloseyourhe'artr.ifo!:aatioaforresearchp-urposesiftheprftracy,slrectoftLer*earchhavebeearevierreg*d;;r;;4 ir rlreseao"l-"r;f;"ff*d#;.t"i'#il**rr.researchproposal ifttre res""ra occriiafte,rior:r dcarrE "r trt; ;;t"rize t!.e use or discl;ser-DisasierRelief' wemaydisclosehealttrinforuationaboutyoutoadisasterrelieforgalizatio,-Ifyou are au.eoeber ofthe arm.ed forces,we may.se aad' disclose yor:rholtr iofom: * r*E ir"aE-=fld; coomaad. arrftorities- weo.aydisclose hea'Ittr' info'-ation fot ""ti-o"rr .G# purposes or as aeeded. io protect the presid.eat oftheurited states or cerrain otre,r omaasiiioliia"o "ertain qecial iavestigations-close yor:r health information to comply witr laws relatingra'mateslT-avr Enforcement cuEto4v- Ifyou are under the custody of a law enforce,o.eart ofEcial or a;E:HH:ilffi tlh5fi Xffi;::'i;lff",#*.;fi -:;:",**ooo",;ffi d.rro;cerraiuApp oirfu'eut Remiader,. we may use or disclose healttr inforamtion to remind, you abo*t appoiufuents- To request aa acoorutiag of-disclosr:res, yorr lmst suboit a request in saiting, stating a tiree pe,riodf"ffi?*nffiI3,2003 tratis witiiasixvears aooot],Ja.i.o-fyo.=r.qoest, iortbesJrequesrs,.weRecnest a P

18 ap er copv of flis NoEce- You hawe.the r
ap er copv of flis NoEce- You hawe.the righr to obtaiu a paper copy of tbis lvotice, eveo ifyou have agreed to receive ttris Notice eleckooically- Y-ou may reEr# u. "opy of ttris Notice at ary time-Reouest Confid'ential communications- You have fte rigLt to request that we ssmnrrrni6.fs with youconce'oing yor:r hea.lth matters iu a ce,rtain malner- we 'wflI accomtodat" yo* ,o"ofiru iuE urts-For disclosr:res conce'miug healttr information relating to care forpsychiatic conditions, substance abuse orrlrv-related testing ard treatr.eug special restrictio*--.y "pply- E"Qt * prowr6ed, below aad. asryecificatiype' itted or required under state or federal 1arq, n"irtn iorofo"uou relatiug to care forpsychiaftic conditions, substance abuse orrffv-related.testingaad.t *C*t*"yaotbe disclosedwithoutyour sp ecial autJrorizatiou" ?wchiaticT'formatioa- ffneededforyor:rdiaguosisorteatueritinamentaLhealthprograu.psychiatricinfom'ationmaybedisclosed- ceraintimited.infolatioamaybedisclosed.forpalr@.entpurposes_' r[v-related'informatiou rfiv-related inforoatioamaybe disclosed.forpuqposes ofteatuentoro Substa:rce abuse tr- eatroenl If you are teated in a pecialized. sr:bstao'ce ab.r:se progra:oc, ;ror:rspecial auororizatiou will be need.ed. for most dis"roi.u-sGot iu"ruairg .-*g#E]vtrfyou have aay questions about this Notice orwor:ld like frrther information conce. ing yowprivacy'ieifs, pl€,.se contact ttre ofrce arz0346g-s2ho aad qeak to tre om"! -*.g.r-Ifyou beiieve ttrat yor:rprivacy rigbts have beer. violate( you must fiie a couplaint in uritiag wittr &eAgencvorwitb'ttreoffi,ceofcivilRightsintheu-s-D?j.tu;;iE"atn.oarft:maaservices- weu:f1' uot retaliate against you if you fl.e a c-ooplaiatTrIL CEANGES TO THI,SNOTTCE'We reserve tLe right to chalge tlis ].Totice al.d. to oake tte revised ornesrNofce provisions effective for.,.i}**f*f-*=y::T:1Td-ri""+"atva"*e*-i--"uasforallhearfl riofo:-ca{oawe rece'i'e io the frtr:re- 'we vfl.r provid.e a copy of ttr " ,;;; fr"ti;-r4, oo ,*E *Name of ladividlal GdnteQSignatr:r'e of Lega1@reheasiveDate Signed _/ /v-Reia