5377 Manhattan Circle, Unit 100

Boulder, CO

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I understand this is a legal agreement and Intend to sign,
I also Agree to sign this agreement electronically.
Terms of consent

Today's Date*

Were you referred? If so, please provide existing patient name, provider name, clinic website, or insurance website?

First Name (include any nickname in parentheses)*

Middle Name

Last Name*

Birthday*

Gender*

Please select one option

Male

Female

Other

Social Security # (last 4 digits only)*

Street Address*

City*

State/Province*

Zip Code*

Marital Status*

Please select one option

Married

Single

Phone*

Home Phone

Spouse's Name

Email*

Your Occupation

Emergency Contact

Emergency Contact Phone*

Your Employer

Work Address

Work City

Work State

Work Zip

Work Phone

May we contact you at work?

Yes

Preferred method of contact?

Home Phone

Cell Phone

Work Phone

Insurance Carrier and Deductible Amount If Known

Policy #

Primary Care Provider's Name

Insured's Last Name

Birthdate

First Name

Middle Name (or Initial)

Who carries this policy?

Self

Spouse

Parent

Insured's Employer*

Address

City

State/Province

ZIP/Postal Code

Are the result of:

Work Accident/Injury

Auto Accident/Injury

Other

Long-term Problem

If Other, Please Explain

Medpay or At fault Auto Insurance?

Medpay (your own)

At fault (eventual responsible party

Auto or Workers Compensation Info (Medpay Claim number, adjuster's name, phone, fax. Attorney's Name. Is this medpay claim number or at fault party?)

Chief complaint
(One complaint per exam but feel free to put multiple in priority order.):

Chief complaint (maximum of 2 but put related complaints if known).

Patient Name

Onset and Mechanism of Injury (When did you first notice your current symptoms?)

Intensity (How extreme are your current symptoms?

0-Absent

5-Uncomfortable

10-Agonizing

Duration and Timing (When did it start and how often do you feel it?)

Constant

Comes and Goes

Quality of Symptoms

Numbness

Tingling

Stiffness

Aching

Cramps

Sharp

Burning

Shooting

Place an X on the image below, where you feel pain, numbness or tingling:

Relevant trauma to same joint or area in years past? Major trauma or similar episodes to same area?

Radiation (any numbness or pain extending into an arm or leg aka sciatica or carpal tunnel like?)

Provoked by: ( What makes it worse, such as time of day, movements, certain positions, activities, etc)

Relieved by? What tends to lessen the problem? (nsaids, oral steroids, epidural steroid injections,restricting an activity, splint, icing, etc)

Prior Diagnostics and Treatment for this Issue.

Prescription medication

Over-the-counter drugs

Physical therapy

Surgery

Acupuncture

Chiropractic

Massage

Ice

Heat

Other

Oral steroids

Epidural steroids

Medial branch block

MRI

Xray

Bone scan

Nerve conduction study

Provider for each treatment and response to each. (Relieved, neutral, aggravated, etc)

Chiropractic cautions: (Have you ever been told you had any of the following or developed these symptoms after being adjusted?)

Dizziness

Facial numbness

Mental confusion

Anxiety about being adjusted

Os odontoideum

Spondylolisthesis

Pain shooting down arm or leg after adjustment

Black spots in vision

Age and Type of Mattress? Firm? Spring or Memory Foam? Type of pillow? Polyfill vs Down vs Memory Foam

Urgency? Sleep loss? Work impacts? Upcoming travel or races? How does your current condition interfere with these necessities?:

Mark your Pain Point

Review of Systems

Some complaints in other body systems are related. Please check the box beside any condition you've Had or Have.

Musculoskeletal

Osteoporosis

Had

Have

Knee Injuries

Had

Have

Arthritis

Had

Have

Foot/ Ankle pain

Had

Have

Scoliosis

Had

Have

Shoulder Problems

Had

Have

Neck Pain

Had

Have

Elbow/ Wrist pain

Had

Have

Back Problems

Had

Have

TMJ Issues

Had

Have

Poor Posture

Had

Have

Hip Disorder

Had

Have

Neurological

Dizziness

Had

Have

Headache

Had

Have

Foot drop or tripping

Had

Have

Numbness

Had

Have

Pins and Needles

Had

Have

Depression or suicidal ideations

Had

Have

Cardiovascular

High Blood Pressure

Had

Have

Deep vein clots or pulmonary clots

Had

Have

High Cholesterol

Had

Have

Excessive Bruising

Had

Have

Angina

Had

Have

Atrial fibrillation

Had

Have

Respiratory

Hay Fever

Had

Have

Emphysema

Had

Have

Apnea

Had

Have

Asthma

Had

Have

Shortness of Breath

Had

Have

Pneumonia

Had

Have

Digestive

Heartburn

Had

Have

Food Sensitivities

Had

Have

Ulcer

Had

Have

Anorexia/Bulimia

Had

Have

Constipation

Had

Have

Diarrhea

Had

Have

Sensory

Blurred Vision

Had

Have

Ringing in Ears

Had

Have

Hearing Loss

Had

Have

Loss of Taste

Had

Have

Loss of Smell

Had

Have

Chronic ear Infection

Had

Have

Skin

Migratory swelling in joints unexplainably

Had

Have

Eczema

Had

Have

Psoriasis

Had

Have

Skin Cancer

Had

Have

Hair Loss

Had

Have

Rash

Had

Have

Endocrine

Frequent Infection

Had

Have

Hypoglycemia

Had

Have

Immune Disorders

Had

Have

Thyroid Issues

Had

Have

Severe osteoporosis or compression fractures

Had

Have

Low Energy

Had

Have

Genitourinary

Kidney Stones or Blood in Urine

Had

Have

Infertility

Had

Have

Bedwetting

Had

Have

Prostate Issues or Frequency of Urination

Had

Have

Erectile Dysfunction

Had

Have

PMS Symptoms

Had

Have

Constitutional

Poor Appetite

Had

Have

Low Libido

Had

Have

Fainting

Had

Have

Sudden Weight Gain/Loss Greater than 15 lbs.

Had

Have

Fatigue

Had

Have

Weakness

Had

Have

Past Personal, Family and Social History

Please identify your past health history, including accidents, injuries, illnesses and treatments. Please complete each section fully.

Illnesses

Check the illnesses you Had in the past or Have now.

Alcoholism

Had

Have

Allergies

Had

Have

Arteriosclerosis

Had

Have

Cancer

Had

Have

Epilepsy

Had

Have

Diabetes

Had

Have

Glaucoma

Had

Have

Goiter

Had

Have

Gout

Had

Have

Heart Disease

Had

Have

HIV Positive

Had

Have

Hepatitis

Had

Have

Polio

Had

Have

Multiple Sclerosis

Had

Have

Rheumatic Fever

Had

Have

Sexually Transmitted Disease

Had

Have

Stroke

Had

Have

Tuberculosis

Had

Have

Inflammatory arthritis

Rheumatoid arthritis

Lupus

Ankylosing spondylitis

Psoriatic arthritis

Reactive arthritis

Ulcerative colitis or Crohn's Ds

Juvenile rheumatoid arthritis

Radiation (any numbness or pain extending into an arm or leg aka sciatica or carpal tunnel like?)

Surgeries

Surgical interventions, which may or may not have included hospitalization.

Family History

Some health issues are hereditary. Tell us about the health of your immediate family members

Are there other Hereditary health issues that you know about?

Social History

Tell us about your health habits and stress levels.

Alcohol use

daily

weekly

How much?

Coffee Use

Daily

Weekly

How much?

Tobacco Use

Daily

Weekly

How much?

Exercising

Daily

Weekly

How much?

Pain Relievers

Daily

Weekly

How much?

Soft Drinks

Daily

Weekly

Water Intake

Daily

Weekly

Financial Peace?

Yes

Who is your Family Physician or Primary Doctor that monitors you?

When was the last time you had blood work done?

Informed Consent and Assumption of Risks

The practice of physical therapy and chiropractic care includes many standard examination, testing, and therapeutic procedures. These include physical examination, orthopedic and neurological testing, specialized screening examinations, radiological (X-Ray) examinations, and laboratory testing. Procedures performed by our physical therapy staff include various modality and rehabilitation procedures. Procedures performed by chiropractic staff include similar rehabilitation techniques and the procedure unique to the chiropractic profession - the chiropractic adjustment. Adjustments are delivered to patients by chiropractic staff or manual therapy by physical therapy staff to correct spinal or extremity (knee, shoulder, wrist, etc.) joint dysfunction. This joint restriction exists when one or more bones of the spine (or extremity) are misaligned or the soft tissues are contracted sufficiently to cause lack of motion within corresponding joints arthritis and degenerative disk disease then eventual disk herniation. The primary goal of these joint mobilizations is to restore joint flexibility, strength, and circulation post-injury or post-operatively following an extended period of disuse and immobilization.

It is not enough that you understand the benefits of these treatment options in restoring normal joint motion and nervous system health; you must also be aware of the risks involved and inherent limitations to care compared to other medical procedures with their own inherent risks. Risks associated with modalities and mobilizations may include thermal burns from heat packs or icing improperly, muscular sprain/strain of adjacent tissues, aggravation of an unstable disk herniation in the treatment of adjacent facet joint problem, aggravation of undiagnosed fracture, aggravation of undiagnosed vertebral artery dissection, and complications arising from preceding risks. Dry needling presents a unique set of risks including aggravation of muscular condition, injury to underlying neurovascular tissues, localized infection, and temporary partial lung collapse in rare circumstances.

The incidence of severe injury due to chiropractic care and physical therapy is exceedingly low (1 in 800,000 range) compared to comparable medical options to treat similar conditions such as steroid injections (1 in 10,000), arthroscopic surgery (1 in 10,000), and micro discectomy (1 in 4500). These medical options have higher incidence and severity of complications including infection, paralysis, stroke, complications of anesthesia, non union of fusion, post surgical fibrosis requiring revision, failure to improve patient's functional status, or permanent neurological symptoms. While seldom are the risks significant enough to contraindicate medical, chiropractic, or physical therapy care, these incidence and severity complication rates should be weighed against each other rather than in isolation in making the decision to receive or not receive any type of care.

If you are at risk, based on identifiable signs or history, you will be notified. It is possible, however, that risks may not be identifiable or apparent to your provider or that your insurance carrier has placed barriers for providers to obtain necessary diagnostic exams. As such, you are encouraged to ask about risks associated with any treatment option offered in both in this office and at other specialties who treat similar neuromuskuloskeletal conditions.

Informed consent is a dynamic partnership process and we welcome your questions before, during, or after your care here at our clinic.

Authorization for Care

I have been informed of the nature and purpose of care, the possible consequences of care, and the potential risks of care; including the risk that care I receive in this clinic may not accomplish the desired objective. I acknowledge that no guarantees have been provided to me with regard to the results of the care I will receive and that questions regarding risks are encouraged at any point in the management of my case.

HIPPA Privacy Practices

Privacy Policy

I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care or treatment.

I understand that this information serves as:

A basis for planning my care and treatment.
A means of communication among the many healthcare professionals who contribute to my care.
A source of information for applying my diagnosis information to my bill.
A means by which a third-party payer can verify that services billed were actually provided.
A tool for routine healthcare operations such as assessing care quality and reviewing the competence of healthcare professionals.
A method for doctor and patient to communicate by email (non secure) or fax (secure) electronically to improve outcomes and access to doctor for follow up recommendations.

I understand that I have the right:

To object to the use of my health information for directory purposes.
To request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or healthcare operations, and that the organization is not required to agree to the restrictions requested.
To revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon.

Records Release Special Restrictions:

Signature*

Date Signed*

Printed Name*

Email*

CLINIC POLICIES

MISSED APPOINTMENTS/LATE RESCHEDULING:

Unless notice provided at least 24 hours business days in advance, we reserve the right to charge a time-based missed appointment/late cancellation fee or place any patient on a same day future scheduling policy. We have voicemail available 24 hours a day, 7 days a week should you need to cancel during non-office hours preferably before Friday 6pm for Monday am appointments. We may have patients waiting for an appointment on a cancellation list; your courtesy of a phone call allows us to schedule them. This charge is not covered by or billed to your insurance.

EMAIL/PHONE CONSULTATION FEE

I understand that I may incur a nominal office fee for extended phone or email consultations requiring physical dictation in lieu of a normal office visit. I also consent to email communications of my medical records, MRI images, etc with other providers and myself as a convenience. No method of communication is completely secure so we do not email communications containing social security numbers, credit card numbers etc. I consent to the convenience of email communications with the intent of more efficient doctor patient communication. This waives some HIPPA protections for the sake of improved patient-provider-provider communication.

RELEASE OF INFORMATION:

I authorize other healthcare providers to release or obtain any medical records, images, or reports to/from Colorado Spine and Sport for the purpose of providing or obtaining medical information pertaining to my treatment. I will specify any restrictions to any party I authorize to receive said information from Colorado Spine and Sport. Note any limitations to that information ie time period, type of records, etc

ASSIGNMENT OF BENEFITS/FINANCIAL POLICY:

I hereby assign payment directly to Colorado Spine and Sport, who represents this clinic to payor groups for medical benefits payable to Colorado Spine and Sport. I also understand that I am financially responsible for any charges not covered by this assignment, including denials for a properly submitted claim. We will submit one claim properly at no charge but may charge $15 to resubmit a properly submitted claim thereafter due to an error on part of the insurance company. I will update billing information as soon as any changes occur in my insurance coverage including my address and personal contact information. I understand and authorize that any unpaid services at 90 days will be charged to the credit card on file from previous office visits unless such charges have been disputed in writing. I also understand applicable statement fees, late charges, 18% annual interest, and legal expenses will also be recovered to reconcile a seriously delinquent account (> 90 days beyond the date of service) or any disparagement published as a result of a disputed billing matter. Additionally, I consent to resolving all legal disputes in binding arbitration before any civil court proceeding.

Health insurance will not be billed for auto accident cases due to the higher documentation standards necessary to document impairment, causation, etc. Auto cases that are awaiting settlement shall pay $100 month towards their balance if your medpay benefit is exhausted during care.

I understand my health insurance is a contract between myself and insurance carrier. No guarantees of coverage are implied by Colorado Spine and Sport. Unique plan requirements like pre-authorization, whereby such requirement is not clear in the initial verification of benefits process, are the responsibility of the patient to be compliant with as those requirements are not always clearly apparent at verification of benefits. Any denials over pre-authorization requirements default to our policy of billing patient's

PHYSICAL THERAPY SERVICES; MEDICAL DIRECTOR AND ADVANCED BENEFICIARY (ABN) NOTICES:

1. I hereby understand and consent that ALL physical therapy services at CSS are billed under my medical benefit with supervision by medical director Eric Traister, MD.This allows for longer appointment duration and lower copays among other benefits. Your insurance explanation will reflect this medical director model of care by Dr. Traister. He reviews all exams and treatment plans in addition to being on call with PT staff for consultation on your case throughout care.
2. BCBS PT patients: Your PT benefit practically speaking covers a 30 minute therapy appointment. This is sufficient for non –surgical cases. More complicated cases will be scheduled for 45 minute appointments that require patient to pay a non-covered service fee of $25 in addition to their copay for this uncovered extra 15 minute contact time. We are focused on what you need not what your insurance covers. This does not apply to chiropractic patient services. Dr. Rodgers is not a Blue Cross chiropractic provider because they limit chiropractic care to adjustment only 15 minute appointments.
3. Medicare PT patients: We are a PT provider for Medicare but not for the supplemental plans. This means you will pay your copay at the time of service and then reimbursement by any supplemental plan will occur directly to you. Dr. Rodgers is not a Medicare chiropractic provider as they limit chiropractic care to adjustment only 15 minute appointments.

The ABN gives you information to make an informed choice about whether or not to receive these services, understanding that you are accepting this transparent, fully disclosed modification to our contracted rate.

Signature*

Date Signed*

Printed Name*

Email*

If the patient is a minor child, print child's full name:

Thank you for taking the time to fill out this form.

REVIEW WAVE ELECTRONIC SIGNATURE TERMS AND CONDITIONS

Updated September 10, 2020

THESE ELECTRONIC SIGNATURE TERMS AND CONDITIONS ARE INCORPORATED BY REFERENCE INTO THE REVIEW WAVE TERMS AND CONDITIONS AND ARE LEGALLY BINDING. By using the Review Wave E-Signature Service, you accept and agree to the terms of these terms and conditions (the "Terms"). Should any conflict arise between these Terms and the Review Wave Terms of Service (the "Standard Terms"), these Terms shall control with respect to the subject matter herein. Both you and Review Wave may be referred to herein individually as a "Party", and collectively as the "Parties".

THE E-SIGNATURE SERVICE.
- Service Description. Review Wave's electronic signature service (the "Service") allows you to signify your agreement with legally binding agreements electronically, in lieu of a pen-and-ink signature on a physical hardcopy. The Service is a "Review Wave Service" for the purposes of interpreting the Standard Terms.
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Authorized Use. You shall use the Service solely for your internal business or personal purposes, and in no case shall you make the Services or any portion thereof available to any third-party.

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- If you are a consumer, nothing in these Terms affects your rights under mandatory German law and these Terms will be interpreted, construed, and enforced in all respects in compliance with mandatory consumer protection laws of Germany. Notwithstanding anything to the contrary herein or within the Standard Terms, if you are a consumer, you may submit a claim to enforce your rights under these Terms to the competent courts in Germany.

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Review Wave has no control over the contents of any Document. Review Wave makes no representation or warranty regarding any transaction sought to be effected by any Document.

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With respect to "consumers", as that term is defined under applicable consumer protection laws imposing the requirement that parties to an electronic contract consent to the method of contracting (among other requirements), Review Wave does not and is not responsible to: i.) determine whether any particular transaction involves a consumer; ii.) furnish or obtain any required consents or determine if any such consents have been withdrawn with respect to the contracting method; iii.) provide any information or disclosures in connection with any attempt to obtain any such consents; iv.) provide legal review of, or update or correct any information or disclosures currently or previously given; v.) provide any such copies or access, except as expressly provided in the Documentation for all transactions, consumer or otherwise; or vi.) comply with any such requirements. You shall be responsible for determining if any contracting party is a consumer, and if so, to comply with all requirements imposed by law as a result thereof.

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INDEMNIFICATION.
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DOCUMENT RETENTION AND DATA PROTECTION.
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"Transaction Data" means metadata associated with a Document, such as transaction history, image hash value, method and time of Document deletion, sender and recipient names, e-mail addresses, signature IDs, and other unique identifiers and time/date stamps.

Protection of Data. You acknowledge that Review Wave has no obligation to protect your data that is stored or transmitted outside of the Services. Review Wave will employ commercially reasonable measures to protect your data from unlawful or unauthorized access, use, alternation, or disclosure during transit and storage within the Services.

GENERAL.
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- Litigation of Intellectual Property. Notwithstanding the parties' decision to resolve all disputes through arbitration, either party may bring enforcement actions, validity determinations, or claims arising from or relating to theft, piracy, or unauthorized use of intellectual property in any state or federal court with jurisdiction or in the U.S. Patent and Trademark Office to protect its intellectual property rights ("intellectual property rights" means patents, copyrights, moral rights, trademarks, and trade secrets, but not privacy or publicity rights) .

Contact Information. If you have any questions, concerns, or complaints about our Services or anything under these Terms or other agreements with us, please contact us at the following email address.

Email: support (at) reviewwave.com

Location

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Office Hours

Our Regular Schedule

Monday:

8:00 am-6:00 pm

Tuesday:

8:00 am-6:00 pm

Wednesday:

8:00 am-6:00 pm

Thursday:

8:00 am-6:00 pm

Friday:

8:00 am-6:00 pm

Saturday:

Closed

Sunday:

Closed

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