Patient Registration Forms

Securely complete your patient registration forms for Best Life Primary Care.

Status *

New Patient

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

Full Name *

Desired Appt Date

Enter Date of Birth Below *

Sex *

Male

Female

Social Security # *

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

IMPORTANT INSURANCE INFORMATION

To patients with Medical Insurance Coverage,

All of our doctors and providers here at Back In Action Medical Center/Best Life Primary Care, have accepted to be a health care provider for certain insurance companies. The insurance you provide us with is a policy you have chosen either as an individual policy or through your employer. Please understand that we DO NOT determine the coverages, stipulations, frequencies, or clauses on your insurance plan. It is your responsibility to understand the coverages, stipulations, frequencies, and clauses in your plan.

Our office staff requests a BASIC “breakdown of benefits” by either Automated service, Fax, or Online.

(It will be electronically generated from your insurance company or clearinghouse)

We then give you an ESTIMATED COPAYMENT/DEDUCTIBLE price based on the information received from your insurance. Please keep in mind that in some cases, if you have a visit(s) in other facilities the maximum or deductibles may change your Out-Of-Pocket expenses. Most of the time we are not aware of other claims that may be processed when we figure out your estimated copay and or deductible. Therefore, you may have to pay more than what was originally calculated as your estimated payment.

Once services are rendered, our billing team will submit the claim to your insurance company with any imaging and or other necessary attachments. Once your insurance company processes the claim, we both will get a breakdown of benefits that will explain in detail what was paid and how it was determined by your insurance carrier.

If there is a balance on your account for the difference that we have collected, you will then receive a bill from our office or be asked to pay it on your next office visit. If there was an overpayment on your account, it will be applied as a credit and will be used for your next date of service.

OUTSIDE LABORATORY AND RADIOLOGISTS

Please understand that BACK IN ACTION MEDICAL CENTER may send lab specimens to an outside laboratory or send X-Rays taken by Back In Action 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 charges as a result of those outside laboratory tests or radiologist. I understand that BACK IN ACTION is not responsible for payment to those laboratories and/or radiologist.

(Please keep I mind that our contracted rates may change year to year with different insurance companies, therefore may result on us making certain debit or credit adjustments to your account.)

Please understand it is your responsibility to update our office with any changes. Including, health insurance, address change, and contact information.

Enter Full Name Below *

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

Clear

Please Enter Today's Date *

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, PMB Health Solutions LLC/dba Back In Action Chiropractic, and M&R Wellness Center, LLC/ dba Back In Action Chiropractic

Dr. Michael Purificati has an ownership in PMB Health Solutions LLC/dba Back In Action Chiropractic and 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. Med Stat Urgent Care

3. Martin County Department of Health

4. Dr. G’s Urgent Care

5. Helix Urgent Care

Alternative Chiropractic facilities in which we do not have ownership:

1. Complete Care Chiropractic

2. Life Chiropractic

3. Vital Wellness Center

4. Keystone Chiropractic

5. Hoffman Chiropractic

Enter Patients Name Below *

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

Clear

Input the Date Below *

If Not Patient, Please Enter Name of Legal Guardian and Relationship *

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 *

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

Please Sign Your Name Below *

Clear

Enter Date Below *

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 #

These Records are Needed for an Appointment on What Date?

Patient/Legal Representative Signature

Clear

Please Enter the Date Below

Appointment No Show Fee

When an appointment is scheduled for you with one of our providers at Back in Action/Best Life Primary Care, 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 confirmation of your scheduled appointment by 5pm day prior your appointment will be canceled and rescheduled for a later date. If you have an appointment scheduled 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.

Patient Full Name *

If Not Patient, Name of legal guardian:

Signature (Sign Here) *

Clear

Date *

Appointment Notifications *

I agree to receive SMS and email appointment updates from Back In Action Medical Center. Opt-out anytime.

Privacy & Billing Procedures

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

Back In Action Medical Center 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 Back In Action Medical Center 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 Back In Action Medical Center 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 my insurance carrier prior to my visit for covered and non-covered benefits and also whether or not Back In Action Medical Center visit will be paid with my in-network 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 Back IN Action Medical Center 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 Back In Action Medical Center 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, attorney’s 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 Back In Action Medical Center 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 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 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 responsibility after 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 here: Patient Guardian or Personal Representative *

Clear

Date

Outside Laboratory and Radiologists

It is my understanding that Back IN Action Medical Center may send lab specimens to an outside laboratory or send x-rays taken by Back In Action Medical Center 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 charges as a result of those outside laboratory tests or radiologists. I understand that Back In Action Medical Center is not responsible for payment to those laboratories and/or radiologists.

Signature 18rww

Clear

Date

Non-Covered Services

It is my understanding that my insurance company may deem my visit to Back In Action Medical Center as a non-covered service and may make me fully responsible for payment of all charges for these services.

Signature 2183b

Clear

Date

Controlled Substance Agreement

This agreement is designed to ensure the safe and appropriate use of controlled substances prescribed by Back in Action Medical Center/Best Life Primary Care. Controlled substances include, but are not limited to, medications such as Xanax, Tramadol, Ambien, Adderall, and similar classes of controlled substance medications.

In accordance with Federal and state law §456.44(3), F.S. which establishes Standards of Practice for physicians prescribing controlled substances, patients must see the physician at regular intervals not to exceed 3 months.

Patient Full Name *

Address *

City *

State *

Country

Zip Code *

Date of Birth *

Patient Phone Number *

Purpose of Agreement: This agreement outlines the responsibilities of both the patient and the medical provider to ensure the responsible use of controlled substances.

1. Patient Responsibilities: 1.1. I understand that controlled substances are prescribed to manage specific medical conditions, and that misuse can lead to serious health risks, including dependency or addiction.
1.2. I agree to take medications exactly as prescribed. I will not alter the dosage or frequency without prior consultation and approval from my healthcare provider.
1.3. I will not share, sell, or trade my medication with anyone under any circumstances.
1.4. I will safeguard my medication to prevent loss or theft. I understand that lost or stolen medications will not be replaced.
1.5. I agree to use only one pharmacy for filling prescriptions for controlled substances. My pharmacy is: Pharmacy Name:

Pharmacy Name *

Pharmacy Phone Number *

1.6. I agree to provide a complete list of all medications I am taking, including over-the-counter drugs, supplements, and other prescriptions.
1.7. I will not seek prescriptions for controlled substances from other healthcare providers without informing Back in Action Medical Center/Best Life Primary Care.
1.8. I understand that I may be asked to provide a urine drug screen (UDS) or other tests to monitor my medication use.
1.9. I understand that early refills will not be authorized.

2. Provider Responsibilities: 2.1. The provider will evaluate the patient's medical condition and determine the appropriate treatment, including prescribing controlled substances if necessary.
2.2. The provider will educate the patient about the benefits, risks, and alternatives to using controlled substances.
2.3. The provider will monitor the patient's condition regularly and adjust treatment as necessary.
2.4. The provider will maintain a confidential medical record of all treatments and prescriptions.

2.5. The provider reserves the right to discontinue prescribing controlled substances if the patient violates this agreement or if it is deemed clinically inappropriate to continue.

3. Termination of Agreement: This agreement may be terminated under the following circumstances:

Failure to comply with any part of this agreement.
Abnormal findings on drug testing (e.g., presence of non-prescribed substances or absence of prescribed substances).
Evidence of misuse, abuse, or diversion of prescribed medications.
Threatening or abusive behavior towards clinic staff.

4. Acknowledgment and Consent: By signing this agreement, I acknowledge that I have read, understood, and agreed to the terms outlined above. I consent to the use of controlled substances as part of my treatment plan and agree to adhere to the responsibilities described in this document.

Signature 236zh

Clear

Date

Consent for Chronic Care Management (CCM)

Consent for Chronic Care Management (CCM), Principal Care Management (PCM), and Advanced Primary Care Management (APCM) Services

As part of an ongoing effort to enhance care coordination for its beneficiaries, Medicare and other commercial insurance companies offer Chronic Care Management (CCM), Principal Care Management (PCM), and Advanced Primary Care Management (APCM) services. These programs are designed to improve the coordination of your care, helping you manage chronic or complex health conditions more effectively.

Each program provides non-face-to-face care management services to support your healthcare needs between office visits. These services complement in-person visits and ensure that you receive continuous support for managing your health.

Eligibility Requirements:

CCM: Requires two or more chronic conditions expected to last at least 12 months and place you at significant risk of functional decline or death.
PCM: For patients with a single high-risk chronic condition that requires regular care coordination and oversight.
APCM: A more advanced level of primary care management aimed at patients needing comprehensive oversight due to complex health conditions.

Services Provided by Back in Action Medical Center / Best Life Primary Care

If you qualify for any of these programs, our healthcare team will:

✔ Develop a comprehensive care plan, available to you in written or electronic form and updated as needed.
✔ Coordinate with other healthcare providers involved in your care, ensuring seamless communication in compliance with state and federal privacy laws.
✔ Assist with care transitions, such as referrals, emergency department follow-ups, and post-hospital discharge management.
✔ Provide 24/7 access to our care team for urgent chronic care needs and ongoing coordination.
✔ Review and track your key health information, including lab results, medications, allergies, and preventive care reminders.

Consent & Billing Acknowledgment

By signing this consent, you agree to:
✅ Allow Back in Action Medical Center / Best Life Primary Care to bill Medicare or your commercial insurance for CCM, PCM, or APCM services on your behalf. These services may be billed once per month, even if you do not have an in-office visit.
✅ Pay applicable copayments and deductibles for these services. The estimated cost for Traditional Medicare patients is $13.00 - $35.00 per month, while commercial insurance plans may have varying costs based on copay/coinsurance policies.
✅ Acknowledge that only one provider can bill for these services per month—if another provider is already furnishing CCM, PCM, or APCM for you, please notify us.
✅ Authorize electronic communication of your medical information with your care team and treating providers as part of coordinated care efforts.

✅ You have the right to stop receiving services at any time (effective at the end of a calendar month) and can do so by notifying Back in action medical center/Best life Primary care of your decision, at which point we will have you sign a termination form.

I permit Back in action medical center/Best life Primary care to bill Medicare and Any Commercial Insurance for Chronic Care Management Services provided to me and understand I will be responsible for applicable co-payments and deductibles.

Full Name

Signature 25k2r

Clear

Date

Consent to The Use of Artificial Intelligence (AI) Technologies

I hereby consent to the use of Artificial Intelligence (AI) technologies during my office visits at Back In Action Medical Center d/b/a Best Life Primary Care and Access 365 Urgent Care. I understand and acknowledge the following:

1. Purpose: The purpose of integrating AI into my healthcare is to enhance the quality and efficiency of medical services provided to me. AI may assist in various aspects of diagnosis, treatment planning, and monitoring of my health condition.

2. Understanding: I understand that AI technologies may analyze my medical history, symptoms, diagnostic test results, and other relevant data to assist healthcare providers in making informed decisions regarding my care.

3. Privacy and Confidentiality: I acknowledge that my personal health information may be used in conjunction with AI technologies. Back In Action Medical Center d/b/a Best Life Primary Care and Access 365 Urgent Care will maintain the confidentiality and security of my health data in accordance with applicable laws and regulations.

4. Limitations: I understand that AI technologies are tools to aid healthcare professionals and may have limitations. The final decision regarding my diagnosis and treatment will be made by my healthcare provider(s) based on their clinical judgment and expertise.

5. Opting Out: I understand that I have the right to opt-out of the use of AI during my office visits. Such opt-out request must be submitted in writing to Back In Action Medical Center d/b/a Best Life Primary Care and Access 365 Urgent Care. I understand that opting out may impact the quality or efficiency of the healthcare services provided to me.

6. Education and Communication: Upon request, Back In Action Medical Center d/b/a Best Life Primary Care and Access 365 Urgent Care will provide me with information and resources Signature 272t1to better understand how AI technologies are used in my care. I will also have the opportunity to ask questions and discuss any concerns I may have regarding the use of AI.

By signing below, I acknowledge that I have read and understood the information provided in this consent form. I voluntarily consent to the use of Artificial Intelligence during my office visits atBack In Action Medical Center d/b/a Best Life Primary Care and Access 365 Urgent Care.

Patient Name

Signature 272t1

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