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NP Intake

Personal Info
Contact Info
Emergency Contact
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History of Present Illness
Area of Complaint

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Review of Systems

Have you had any of the following conditions in the PAST?

Health History

Do you or any of your immediate family have any of the following?

Family History

COVID Pre-Screen Questionnaire (Accept and Sign below)

To help minimize the risk to myself and other patients, please certify below that the following statements are true:

  1. In the past ten days, I have not come into contact with anyone who has tested positive for COVID-19 (Corona Virus).

  2. In the past week, I have not tested positive for COVID-19 (Corona Virus).

  3. In the past two days I have not experienced any of the following symptoms:

    • Fever
    • Productive Cough
    • Respiratory infection

Health Insurance Portability and Accountability Act (HIPAA) (Accept and Sign below)

Download available below.

Office Policy (Accept and Sign below)

  1. Insurance. This office operates as a Direct Primary Care facility, and as such, cannot participate with any insurance plans, including Medicare (see #2). If you choose to pay-as-you-go in a “Fee for service" manner, you can submit our bills to your insurance for reimbursement (see #3).
  2. Medicare. This office does not participate with Medicare. Chiropractors are the only health profession that is not allowed to see Medicare beneficiaries if the provider doesn't participate with Medicare. Therefore, if this office is aware that you are a Medicare beneficiary, we are legally obligated to refer you to another chiropractic provider.
  3. Claims Submissions. This office will, at your request, provide any information you need to submit to your insurance.  For most cases, this requires a "Superbill", which can be generated at your request after at least two visits. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance pays your claim. Your insurance benefits are a contract between you and your insurance company, we are not party to that contract.
  4. FSA/HSA. This office accepts payments from FSA and HSA accounts. Should you require more information for reimbursement, please contact the office in writing and we will do our best to provide you with any information you need to be reimbursed.
  5. Card Authorization.  Cuse Chiro uses and EHR system that automatically stores your credit card for future purchases, including late fees (#7).  Therefore, I, authorize Cuse Chiro, Inc to charge my credit card for agreed upon purchases. I understand that my information will be saved on file for future transactions on my account.
  6. Late Fees.  In an effort to keep fees low, the office charges reflect a "time of service" charge.  In light of COVID-19, we started utilizing contactless payments in the form of Invoicing to your email address.  With this method of payment, we don't expect payments to be received at the time that the service is rendered.  However, we do request that these invoices be paid as soon as possible.  Invoices that are not paid after 7 days may be subject to a $5 "Time of Service" Fee.  In addition, Invoices that remain delinquent at 30, 60, and 90 days will incur a 10% late fee and will continue to incur late fees until payment is made.  Failure to pay will result in submission of debt to debt collection (see #8).
  7. Missed Appointments. Patients will be charged $25.00 for missed appointments not cancelled 24 hours in advance. The charges will be your responsibility and must be paid prior to your next appointment.
  8. Collections. Unpaid balances will be sent to collections. If your balance is sent to collections, you will be responsible for an additional 30 percent of the remaining balance to be added to the original amount sent to collections.
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