Patient Registration Forms

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

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

Insurance Information

In Case of Emergency

Reason for Today's Visit

Medical History

Family History

Social History

Review of Systems

(Check all that apply)


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.


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.


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 of 1992,” 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


Medical Information Release Form

(HIPPA Release Form)

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

Release of Information



Informed Consent for Disclosure of Medical Health Information

I authorize the following health care provider:

To Disclosure to the Following Party:


When an appointment is scheduled for you with Michael Carpino or Misty Gaddis 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 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.