Immediate Care Form | Cornelia, GA

Immediate Care

Date:

Patient's Name:

Date of Birth:

Sex:

Cell #:

Home#:

Work #:

E-mail address:

May we send you text/email reminders?

Yes

Address:

City:

State:

Zip Code:

Where did you hear about us?

Emergency Contact Information:

Emergency Contact Information:

Name:

Phone #:

Relationship:

Insurance Information: (Please make sure and give your insurance information to office staff)

Insurance Information: (Please make sure and give your insurance information to office staff)

Insurance Information:

Health Insurance

Self Pay

Pharmacy

Chief Complaint:

Chief Complaint:

(Why you are here today)

Are you pregnant?

Date of last menstrual cycle?

Do you have any drug allergies?

Please list:

Do you take any medications daily?

Please list:

Medications, Vitamins and Herbal Supplements

Medications, Vitamins and Herbal Supplements

Example:

Medication : Tylenol

Strength : 500 mg

Number of pills taken & frequency: 1 - twice daily

Medication

Strength

Number of pills taken & frequency

Medication

Strength

Number of pills taken & frequency

Medication

Strength

Number of pills taken & frequency

Patient Health Information Consent Form

Patient Health Information Consent Form

The patient understands and agrees to allow Spinal Rehab and Healthcare, LLC 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 Spinal Rehab and Healthcare, LLC to submit requested PHI to the Health Insurance Company (or companies) provided to us by the patient for the purpose of payment.

Additionally, the patient acknowledges that Spinal Rehab and Healthcare, LLC utilizes Artificial Intelligence (AI) software to assist in generating accurate and efficient clinical documentation for health records. This technology is used solely to enhance the quality of care and ensure comprehensive documentation of patient encounters.

1. The patient has the right to examine and obtain a copy of his/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.

2. A patient's written consent need only be obtained one time for all subsequent care given to the patient in this office.

3. 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.

4. 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 assure that your records are not readily available to those who do not need them.

5. Patients have the right to file a formal complaint with our privacy official about any possible violation of these policies and procedures.

6. If the patient refuses to sign this consent for the purpose of treatment, payment, and health care operations, the physicians have the right to refuse to give care.

I have read and understand how my Patient Health Information will be used and I agree to these policies and procedures. I have read and understand how my Patient Health Information will be used and I agree to these policies and procedures.

Patient's Signature:

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Agreement for Payment of Services

Agreement for Payment of Services

Agreement for Payment of Services

The undersigned agrees that he/she/they are fully responsible for the total payment of all procedures and treatment performed in this

office, Spinal Rehab and Healthcare, LLC – this includes any treatment that is not a benefit of any insurance that I/We may have. I/We

understand that all payment for services is due and payable at the time the services are rendered. I/we agree to pay interest on all

outstanding amounts owed in the amount of one and a half percent (1½%) per month (18% per annum) on all amounts outstanding for

more than sixty days from the treatment date, regardless of whether or not insurance benefits have been received. I/We further

acknowledge and agree that I/We am personally responsible for payment of all services and that billing to my insurance company is

provided as a convenience. This office will help prepare insurance forms or assist in making collections from insurance companies and

will credit any such amounts received to the patient’s account. However, this office cannot render services on the assumption that our

charges will be paid by an insurance company. In consideration for the professional services rendered to the above-named patient, I/We

agree to pay the reasonable value of said services to Spinal Rehab and Healthcare, LLC, according to the normal rates and fees, at the

time of treatment. I/We further agree that the reasonable value of said services shall be billed unless objected to, by me, in writing,

within ten days of the time for payment thereof. I/We further agree that I/We will be responsible for reasonable attorney’s fees in the

amount fifteen percent (15%) of the amount outstanding if collected by or through an attorney at law. I/We agree that if more than one

party is listed below, that each of us is jointly and severally responsible for payment of these obligations.

I/We have read the above conditions of payment and agree to their content.

Patient Signature (if over 18 years of age)

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Signature of Responsible Party (if under 18 years of age)

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Print name of responsible party

Relation to Patient

706-778-0077

Business Hours

Mon - Fri: 8:00 am - 5:00 pm
Sat - Sun: Closed

Address

186 Cannon Bridge Road

Cornelia, GA 30531

Payment Options

More Info

Walk-ins Welcome

Most Insurance Accepted

Care Credit Accepted

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