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QiroFit · Chiro · Physio · Fitness

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New patients

Save time before your first visit.

Completing your intake forms ahead of time is optional, but it gets your first appointment with Ken Ycmat, D.C. started faster. Prefer paper? You can also fill everything out when you arrive.

Your privacy: Nothing you type here is sent to us or saved online. Everything stays in your browser until you print or save it, so please complete the form in one sitting. Bring the printed copy to your visit. Payment-card details are collected securely in the office, never on this form.

  1. Fill in the sections below. Your browser can autofill name, address, phone, and email for you.
  2. Choose Print / Save as PDF at the bottom when you are done.
  3. Sign the printed copy and bring it to your appointment, or print it blank and fill it in by hand.

Questions? Call us at (323) 599-0312.

Section 1

Patient information

Marital status

Section 2

Contacts

Spouse or parent/guardian
Emergency contact
How did you hear about us?

Section 3

Insurance information

Optional. All costs may be offset by health insurance. We accept cash, checks, Visa, MasterCard, Amex, and most insurance policies. Payment-card details are collected securely in the office, not on this form.

Section 4

New patient questionnaire

2. Are you experiencing any of the following symptoms related to your main concern? Check all that apply.

Constitutional
Eyes
Ears, nose, mouth & throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Skin
Neurological
Musculoskeletal
Psychiatric
Endocrine
Hematologic
Allergic
3. Do you have any other concerns?
4. Do you have any drug allergies?
6. Do you currently have, or have you previously had, any major medical problems?
7. Have you had any surgeries?
8. Does anyone in your family have a medical illness such as diabetes, high blood pressure, high cholesterol, cancer, or other?

Section 5

Office policies

Welcome

Thank you for choosing QiroFit for your health care needs. All patients receive a full chiropractic evaluation, after which our Doctor of Chiropractic decides what course of treatment, if any, will benefit you. All treatments are provided under the direction and supervision of our qualified, board-certified chiropractor.

Financial policies

We follow California State Insurance Laws. All patients are responsible for their deductibles and co-payments. For these reasons, insurance billings, receipts, and statements for every procedure or treatment are billed under QiroFit. We have only one set of fees, which are set by the State of California Relative Value System.

Payment policies

All visits must be paid in full at the time of service unless prior arrangements have been made and approved by our office manager. The only exceptions are: (1) Personal Injury with a lien signed by an attorney, and (2) approved Workers' Compensation patients, who are not required by law to pay for their own treatment unless it is self-procured. We gladly accept cash, checks, Visa, MasterCard, Amex, and most insurance policies.

Appointment & cancellation policy

All visits are by appointment. Emergency patients are seen on a first-come, first-served basis or between regularly scheduled patients. When we schedule your visit, we reserve that time specifically for you. If you need to change or cancel an appointment, please give 24 hours' notice, or you may be charged a $50 cancellation fee. Payment-card details for any applicable fee are collected securely in the office, not on this form.

Section 6

Patient Health Information Consent

We want you to know how your Patient Health Information (PHI) is used in this office and your rights concerning those records. Before we begin any health care operations, we ask you to read and sign this consent stating that you understand and agree with how your records will be used. If you would like a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information, please ask to read the HIPAA Notice available at the front desk before signing this consent.

  1. The patient understands and agrees to allow QiroFit to use their Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operations, and coordination of care. As an example, the patient agrees to allow this office to submit requested PHI to the health insurance company (or companies) provided to us by the patient for the purpose of payment. Be assured that this office will limit the release of all PHI to the minimum needed for what the insurance companies require for payment.
  2. The patient has the right to examine and obtain a copy of his or her own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI. Our office is not obligated to agree to those restrictions.
  3. A patient's written consent need only be obtained one time for all subsequent care given to the patient in this office.
  4. The patient may provide a written request to revoke consent at any time during care. This would not affect the use of those records for the care given prior to the written request to revoke consent, but would apply to any care given after the request has been presented.
  5. For your security and right to privacy, all staff have been trained in the area of patient record privacy, and a privacy official has been designated to enforce those procedures in our office. We have taken all precautions known by this office to ensure that your records are not readily available to those who do not need them.
  6. Patients have the right to file a formal complaint with our privacy official about any possible violations of these policies and procedures.
  7. If the patient refuses to sign this consent for the purpose of treatment, payment, and health care operations, the physician has the right to refuse to give care.

Section 7

Consent for treatment: I voluntarily consent to the rendering of care, including treatment and the performance of diagnostic procedures. I understand that I am under the care and supervision of the attending chiropractor, and it is the responsibility of the staff to carry out the instructions of the chiropractor.

Assignment of benefits: I hereby assign payment directly to QiroFit for benefits applicable and otherwise payable to me, but not to exceed the physician's regular charges. I specifically direct any second or third party to accept this assignment and pay the physician directly. I understand that I am financially responsible for charges that the insurance carrier declines to pay. In the case that a check is made to the patient or this office for services rendered by this office, this document serves as a power of attorney for endorsement on the patient's behalf.

Lien: In the event that a lien is necessary to protect and ensure payment to QiroFit, this document serves as notice of lien on any claim I may have and serves as a power of attorney for signature on my behalf on such lien form should it be needed.

Release of information: I authorize the release of information contained in my chart to relevant insurance companies, third parties, attorneys, and employers as may be needed to process and manage my case and claims.

Request for information: I authorize any custodian of records to release medical records and diagnostic studies (including X-rays) to QiroFit for the purposes of case management.

HMO disclaimer: I certify that I am not presently enrolled in any Health Maintenance Organization (HMO). Subsequent rejection of a claim as a result of my enrollment in an HMO will constitute responsibility for payment of the claim on my part.

Minor's release: If the patient is a minor, my signature as parent or guardian authorizes any needed examination and treatment for the minor.

Pregnancy: There is no reason to suspect that I might be pregnant at this time. If there is a possibility that I might be pregnant, I will advise the doctor prior to any X-ray or onset of care.

Section 8

Signature

Print this completed form and sign it by hand, or bring it to your appointment to sign in person. Your signature confirms the consents above.

Signature