APPLICATION FOR CARE AT IANNELLI WELNES CENTER
HISTORY OF COMPLAINT
Please identify the condition(s) that brought you to this office:
On a scale of 1 to 10 being the worst pain and zero being no pain, rate your above complaints by circling the number:
Please Mark an "X" on the diagram to describe where your symptom areas are :
Like and follow us on Facebook for office updates and hours.
PAST HISTORY
Please indentify any and all types of jobs you have had in the past that have imposed any physical stress on you or your body:
If you have ever been diagnosed with any of the following conditions, please indicate with a P for the Past and a C for Currently:
PLEASE identify ALL PAST and any CURRENT conditions you feel may be contributing to your present problem:
INJURIES
SURGERIES
CHILDHOOD DISEASES
ADULT DISEASES
SOCIAL HISTORY (Please choose)
Hobbies-Recreational Activities-Exercise Regime: How does your present problem affect the following, See Activities of Life
FAMILY HISTORY
I hereby authorize payment to be made directly to lannelli Wellness Center, for all benefits which may be payable under a healthcare plan or from any other collateral sources. I authorize utilization of this application or copies thereof for the purpose of processing claims and effecting payments, and further acknowledge that this assignment of benefits does not in any way relieve me of payment liability and that I will remain financially responsible to lannelli Wellness Center for any and all services I receive at this office.
Activities of Daily Living/Symptoms/Medications
Daily Activities: Effects of Current Conditions on Performance
Please identify how your current condition is alfecting your ability to carry out routine activities
Please choose if it was in the Past, Currently have, or Never
lannelli Wellness Center
Notice of Privacy Practice
This office is required to notify you in writing that, by law; we must maintain the privacy and confidentiality of their personal health information ("PHI"). In addition, we must provide you with a written notice concerning your rights to gain access to your health information ,and the potential circumstances under which, by law, or as dictated by our office policy ,we are permitted to disclose information about you to a third party without your authorization. Below is a brief summary of these circumstances. if you would like a more detailed explanation, one will be provided for you. Once you have read this notice, please sign the last page and return only the signature page (page 2) to our office desk receptionist. Keep this page for your records.
Permitted Disclosures:
1. Treatment Purposes - discussion with other healthcare providers involved in your care.
2. Inadvertent disclosures -open treating area means open discussion. If you need to speak privately to the
doctor, please let our staff know so we can place you in a private consultation room.
3. For payment purposes -to obtain payment from your insurance company or any other collateral source.
4.For worker's compensation purposes -to process a claim or aid in the investigation.
5.Emergency -in the event of a medical emergency, we may notify a family member.
6.For the public health and safety- in order to prevent or lessen in a serious imminent threat to the health
or safety of a person or general public.
7. To government agencies or law enforcement -to identify or locate a suspect, fugitive, material witness or
missing person.
8. For military, national security, prisoner and government benefit purposes.
Deceased persons -discussion with coroners and medical examiners in the event of the patient's death.
10. Telephone calls, text messages, emails and appointment, reminders - we may call your home and leave
messages regarding a missed appointments, or apprise you of changes in practice hours for upcoming
events.
11. Change of ownership -in the event this practice is sold, the new owners would have access to vour PHI.
Your Rights:
1. To receive an accounting of disclosures.
2. To receive a paper copy of the comprehensive detail privacy notice.
To request mailings to an address different than residential.
4. To request restrictions on certain uses and disclosures and with whom we release information to,
although we are not required to comply. If, however, we agree, the restriction will be in place until
written notice of your intent to remove the restriction.
5. To inspect your records and receive one copy of your records at no charge, with notice in advance.
6. To request amendments two information. However, like restrictions, we are not required to agree to
them.
7. To obtain one copy of your records at no charge, when timely notice is provided (72 hours).
Complaints:
If you wish to make a formal complaint about how we handle your health information, please call the lannelli Wellness Center at (856)227-3480. If the office manager is unavailable, you may make an appointment with the receptionist within 72 hours or 3 working days. If you are still not satisfied with the way this office handles your
complaint, vou could submit a formal complaint to:
DHHS, Office of Civil Rights
200 Independence Ave. SW
Room 509F HHH Building
Washington DC 20201
Page 1 of 2
lannelli Wellness Center
Notice of Privacy Practice continued.
I have received a copy of the lannelli Wellness Center's patient privacy notice. I understand my rights as well as the practice's duty to protect my health information and have conveyed my understanding of these rights and duties to the doctor. I further understand this office reserves the right to amend the "Notice of Privacy Practice" at any time in the future and will make the new provisions effective for all information that it maintains past and present.
At this time, I do not have any questions regarding my rights or any of the information I have received.
Informed Consent
Regarding: Chiropractic Adjustments, Modalities, and Therapeutic Procedures:
They have been advised that chiropractic care, like all forms of health care, holds certain risks. While the risks are most often very minimal, in rare cases complications such as sprain /strain injuries, irritation of a disk condition, and although very rare minor fractures and possible stroke, which occurs at a rate between one instance per one million to one per two million have been associated with chiropractic adjustments.
Treatment objectives as well as the risks associated with chiropractic adjustments and, all other procedures provided at the lannelli Wellness Center have been explained to me to my satisfaction and I have conveyed my understanding of both to the doctor. After careful consideration, I do hereby consent to treatment by any means, method and /or techniques the doctor deems necessary to treat my condition at this time throughout the entire clinical course of my care.
YOUR HEALTH INSURANCE is your policy. We will do everything to advocate for your policy.
I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.