Patient Registration Forms

Securely complete your patient registration forms for Back In Action.

Status *

New Patient

Returning Patient - If so, you can exit the page as we have your information.

Full Name *

Enter Date of Birth Below *

Sex *

Male

Female

Social Security # *

Address *

City *

State *

Zip Code *

Phone *

Please select the option that applies to your primary phone number. *

Cell

Home

Work

Secondary Phone Number

Preferred Contact Method *

Phone

Text

Email *

To be used for provider communication, follow up, patient portal, and practice related material. We DO NOT share email information with other parties. You may choose to remove any time

Employer *

Job Title *

Preferred Language *

English

Spanish

Other

Please enter other language if applicable.

Preferred Pharmacy *

Insurance Information

Policy Holder's Date of Birth *

Primary Insurance Company *

Name of Policy Holder *

Same as above

Other

Please enter the name of the policy holder if "other" was selected above.

Policy Holder's Relationship to Patient *

Self

Mother

Father

Other

If "Other" was selected above please enter the relationship to the policy holder below

Policy Holder's Social Security # (Only required if different than above)

Subscriber Number *

Group Number *

Upload a copy of your insurance card [FRONT]

Upload a copy of your insurance card [BACK]

Please enter the name of your Secondary Insurance Company if applicable

Name of Secondary Policy Holder if applicable

Secondary Group Number if applicable

Secondary Subscriber Number if applicable

In Case of Emergency

I hereby give permission to disclose and discuss any information related to my medical condition(s) with the following listed individual: *

Please enter your relationship with the above listed individual. *

Please enter your emergency contacts phone number. *

Permission to contact: *

Yes

Emergency Contact #2

Please enter your relationship with emergency contact #2

Please enter your emergency contact #2's phone number.

Permission to contact emergency contact #2

Yes

Reason for Today's Visit

Please Describe Symptoms *

Onset/Injury Date

Please list other treatment received if not shown above

Please list current medications prescribed by another provider or anything you are taking over the counter. Enter "n/a" if not applicable. *

Please enter the dosage of the medications listed above. Enter "n/a" if not applicable. *

Condition(s) that requires the medications listed above. Enter "n/a" if not applicable. *

Medical History

If you selected cancer or other, please elaborate on the condition:

Please list medication allergies and the allergic reaction that occurs below. Enter "N/A" if not applicable. *

Please list supplement allergies and the allergic reaction that occurs below. Enter "N/A" if not applicable. *

Please list food allergies below and the allergic reaction that occurs. Enter "N/A" if not applicable *

Please list other allergies below. Enter "N/A" if not applicable. *

Please list any other surgical history. Enter "N/A" if not applicable *

Any hospitalizations besides surgery? *

Yes

Family History

Mother *

Alive

Deceased

Adopted/Unknown Family History

Father *

Alive

Deceased

Adopted/Unknown Family History

ADD/ADHD *

Mother

Father

Other

None

Please enter the relationship to affected family member if "other" was selected above.

Alcoholism/Substance Abuse *

Mother

Father

Other

None

Please enter your relationship to the family member if other was selected above.

Alzheimer's/Dementia *

Mother

Father

Other

None

Please enter your relationship to the family member if other was selected.

Arthritis *

Mother

Father

Other

None

Please list the relationship to your family member if other was selected above.

Asthma *

Mother

Father

Other

None

Please list the relationship to affected family member if other was selected above.

Auto Immune Disease (ex: Lupus) *

Mother

Father

Other

None

Please provide the relationship to your family member if other was selected above.

Cancer (please elaborate below if selected) *

Mother

Father

Other

None

Please provide the relationship to the family member if other was selected above.

COPD *

Mother

Father

Other

None

Please input the relationship to the affected family member if other was selected above.

Diabetes *

Mother

Father

Other

None

Please input your relationship to the affected family member if other was selected.

Eczema/Psoriasis *

Mother

Father

Other

None

Please enter your relationship to the affected family member if other was selected.

Heart Disease *

Mother

Father

Other

None

Please enter your relationship to the family member if other was selected.

Hemodialysis *

Mother

Father

Other

None

Please enter the relationship to the affected family member if other was selected.

Hepatitis *

Mother

Father

Other

None

Please enter the relationship to your affected family member if other was selected.

High Blood Pressure *

Mother

Father

Other

None

Please enter the relationship to your affected family member if other was selected above.

High Cholesterol *

Mother

Father

Other

None

Please list your relationship to the family member if other was selected above.

Kidney Disease *

Mother

Father

Other

None

Please list the relationship to the affected family member if other was selected above.

Obesity *

Mother

Father

Other

None

Please list the relationship to the family member if other was selected above.

Psychiatric Disorder *

Mother

Father

Other

None

Please list the relationship to your affected family member if other was selected above.

Seizure Disorder *

Mother

Father

Other

None

Please list the relationship to your family member if other was selected.

Stomach or GI Problems *

Mother

Father

Other

None

Please list your relationship to the affected family member if other was selected above.

Stroke/ITA *

Mother

Father

Other

None

Please list the relationship to your affected family member if other was selected.

Thyroid Problems *

Mother

Father

Other

None

Please list the relationship to the affected family member if other was selected.

Social History

Amount/Day *

Number of years: *

How many alcoholic beverages do you consume per week? *

How many caffeinated drinks do you consume per day?

Drug Use: *

No history of recreational drug use

Former use of recreational drugs

Current use of recreational drugs

How do you spend most of your time at work? *

Sitting

Standing

Walking

N/A

How many hours do you work per week? *

Review of Systems

(Check all that apply)

Constitutional *

Weight Loss

Fatigue

Fever

N/A

Respiratory *

Cough Easy

Wheezing

Chills

N/A

Endocrine *

Loss of hair

Heat/Cold Intolerance

N/A

Psychiatric *

Anxiety/Depression

Mood Swings

Difficulty Sleeping

N/A

Hematology/Lymph *

Brusing

Gums Bleed Easily

N/A

Skin *

Rash/Sores

Lesions

Itching/Burning

N/A

Medical Information Release Form

(HIPPA Release Form)

This Release of Information will remain in effect until terminated by me in writing.

First and Last Name *

Enter Date of Birth *

Please enter your signature in the box below *

Clear

Enter Date Below *

Release of Information

I authorize the release of information including the diagnosis, records, examination rendered to me, and claims information. This information may be released to:

Please enter the relationship to the individual you are authorizing the release of information below.

Select "Do Not Release" below if information is not to be shared with any one.

Do Not Release

Messages

How should we contact you by phone? *

Home

Cell

Work

If unable to reach you: *

You may leave a detailed message

Please leave a message asking me to return your call

Other

If "Other" was selected above please enter details below.

What times are best to reach you? *

Morning

Early Afternoon

Late Afternoon

Informed Consent for Disclosure of Medical Health Information

First Name

Last Name

Please Enter Your Date of Birth Below

I authorize the following health care provider:

Disclosing Parties Name (Health Care Provider)

Disclosing Party's Street Address

Enter Disclosing Parties Phone Number

Fax Number

To Disclosure to the Following Party:

Disclosing Party's Name - Health Care Provider

Enter their Street Address

Enter Phone Number

Fax #

Patient/Legal Representative Signature

Clear

Please Enter the Date Below

When an appointment is scheduled for you, it is your responsibility to confirm your appointment 24hrs prior to the appointment time. The front desk team will call and or email you to confirm your appointment. In the event you do not answer a voice mail will be left. If you as the patient do not make conformation of your scheduled appointment within 24hrs your appointment will be canceled and rescheduled for a later date. If the appointment is confirmed and you do not show up, you will be billed a $50.00 no show fee. We understand that circumstances will arise that will result in you having to cancel please give us a courtesy call 24hrs prior to your scheduled time to prevent the no show fee being charged.

We value you as one of our patients and hope you understand why this is a necessary office policy.

Please sign and date below stating your acknowledgement of this policy. *

Clear

Please Enter Today's Date Below *

Ownership Notice to Patients

Because of concerns that there may be a conflict of interest when a physician refers a patient to a health care facility in which the physician has an ownership interest, Florida passed a law (the “Patient Self-Referral Act of1992,” FL Statute Section 455.654). Under this law, I must disclose my ownership in this facility and tell you about alternative places where you may go to obtain these services. This disclosure is intended to help you make a fully informed decision about your health care. You have the right to obtain healthcare items or services at a location or from a provider or supplier of your choice, including the facility in which I am owner. I assure you that you will not be treated differently if you do not choose the facility listed below in which I have an ownership interest. Dr. Robert McLaughlin has an ownership in: Back In Action Medical Center, LLC, Proactive Health and Wellness, dba Back In Action Chiropractic, and Access 365 Urgent Care, and M&R Wellness Center, LLC/ dba Back In Action Chiropractic. Dr. Michael Purificati has an ownership in M&R Wellness Center LLC/dba Back In Action Chiropractic

Alternative Medical facilities in which we do not have ownership:

1. Jensen Beach Urgent Care

2. MD Now

3. CareSpot

4. St. Lucie Department of Health

5. Martin Emergency

Alternative Chiropractic facilities in which we do not have ownership:

1. Urgent Care Chiropractic Pain Center

2. Key Chiropractic

3. Back To You Chiropractic

4. Expedition Chiropractic

Patient Full Name *

Signature (Sign Here) *

Clear

If Not Patient, Name of legal guardian:

Date *

Access 365 Urgent Care/Back In Action Medical Center LLC/Best Life Primary Care

PRIVACY & BILLING PROCEDURES

AUTHORIZATION & ACKNOWLEDGEMENT

These authorizations, acknowledgements and waivers cover all services rendered to the above patient for today and all future dates of service. You may submit written revocation of the authorization.However, your decision to revoke the authorization will not affect or undo any events that occurred before you notified us of your decision to revoke.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Access 365 Urgent Care, LLC (A365UC) and Back In Action Medical Center, LLC (BIAM)reserve the right to modify the privacy practices outlined in the Notice of Privacy Practices. I have had the opportunity to read or have received a copy of the Notice of Privacy Practices for the patient outlined above.

AUTHORIZATION TO TREAT AND BILL

I give consent and authorization to A365UC and/or BIAM to examine and provide all routine medical care, diagnostic procedures, disposing of any specimens or tissue taken from my body, and provide treatment in the judgment of the medical provider, necessary or beneficial to my health and well-being with no guarantees expressed regarding the results of examination and treatment by aforementioned facility.

I authorize the release of any medical and demographic information necessary to process all claims. I authorize payment of medical benefits to A365UC and/or BIAM for all services performed.

I understand that I am responsible for all charges incurred at the time of service unless other arrangements were made prior to being treated. I will pay any deductible, co-payments, and any amounts denied or not covered by insurance. I understand it is my responsibility to check with myinsurance carrier prior to my visit for covered and non-covered benefits and also whether or not A365UC and/or BIAM visit will be paid with my innetwork or out-of-network benefits billed as urgent care place of service (POS 20).

I understand that if I do not provide complete and accurate billing/insurance information at the time of service and this lack of information prevents A365UC and/or BIAM from collecting from my insurance company, I will be responsible for the full charges. If a referral or additional forms are required by my insurance company, I understand I am responsible for providing A365UC and/or BIAM with a referral within 48 hours of my visit and/or complete all insurance required forms in a timely manner, or I may be responsible for all charges.

Collection Fees: If payment is not made as agreed upon, the account will be turned over for collection. The patient and/or guarantor, shall be responsible for and agree to pay all reasonable cost of collection including, but not limited to, reasonable collection agency fees, attorneys fees, and court costs.

Jurisdiction and venue: If any suit must be filed to collect an unpaid balance on an account, patient, and/or guarantor, agrees that such suit may be brought in courts of Martin County, Florida, and waives any objection to jurisdiction or venue.

Assignment & Release: I hear by request and assign directly to A365UC and/or BIAM all medical benefits, if any otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, including collection fees and/or interest that may accrue, whether or not paid by insurance. I hereby authorize the provider to release all information necessary to secure the payment of benefits unless written notice is given to revoke this authorization. I authorize the use of a copy of this signature is as valid as the original signature on all of my insurance submissions. Co-pays and Quick Pay fees are due at the time of service. All account balances will be the patient's and/or guarantor's responsibilitynafter processing of insurance if applicable, and may be assessed and $15.00 statement fee per invoice. Full balance is due within 15 days or upon receipt of the first invoice.

Please Sign Below: Parent, Guardian, or Personal Representative. *

Clear

Today's Date *

OUTSIDE LABORATORY AND RADIOLOGIST

It is my understanding that A365UC and/or BIAM may send lab specimens to an outside laboratory or send x-rays taken by A365UC and/or BIAM to an outside radiologist for over reading. I give permission for those outside laboratories and radiologists to bill my insurance for their services. I understand that I may incur additional chargers as a a result of those outside laboratory tests or radiologists. I understand that A365UC and/or BIAM is not responsible for payment to those laboratories and/or radiologist.

Please Sign in the Box Below: Parent, Guardian, or Personal Representative. *

Clear

Please Enter Today's Date *

NON-COVERED SERVICES

It is my understanding that my insurance company may deem my visit to A365UC and/or BIAM as a non-covered service and may make me fully responsible for payment of all charges for these services.

Please Sign the Box Below: Parent, Guardian, or Personal Representative. *

Clear

Input the Date Below *

Virtual Visit Preferred?

Yes

Appointment Notifications *

I agree to receive SMS and email appointment updates. Opt-out anytime.

If form does not submit, please review entire form for missing required fields.