MCCARTER HEAITH CEIYTER43 I 5 EMERSoN AvE, PARKIRSBURG, wv 26 I 04

(304) 428-8300Fnx: (304) 428-5087

New PeIeHT INFoRMATIoNPlease Prinf all Answers

Name

Address

Phone Work

Which #

Birthdate

Age

City

Sex Date

zip

CellBest time to Call

Social Security #

0 Marneo I single

Employer

Employer Address

Employer Phone

Parent's Employ€r lf Patient ls Minor / Chitd

Parents Social Security # lf Patient ls Child

Emergency: Who Do We Call?

0 Sep nDivorced 0 Widowed Spouse,s Name

E-mail

Family Doctor

Spouse's Employer

Spouse's Birthdate

Spouse's Social Security

Relationship

Name of Insured (Policy Holder)

Insured Birthdate

Group Number

Policy Number

Name of YOUR Auto Insurance Company

Agent Name

Accident Claim NumberAdjusteis Name

Phone Number

Adjustefs Name

Phone Number

Phone Number

Name of LIABLE Insurance Company

Claim Number

Attorney Name

Employer or Responsibte Party

Contact Person Phone Number

w€|co.n€|ooumu|li€poC:bltygrouppr.ctbe,of€ring.fahi'pf*thet.peinnEna9d|€nlm€dl,-ca'6'.hi'op..c1ic.phFica|fEIapy.t6hau|ile|bn,elFln<,Ur6,m|hor.py.nul'iti'ta|aFFholoo|c.|co.ltE€I[o.w€wI|*i;'ron"rp'.iro."o.r'nf.;oU'}Ea[hbutth€{oe.€no!UaEn|eeso.p.o'nEl6o.i|nFoveI'|en|orcom.recover' Palktnts are dcotrreg€d to hove raluat{es a nome, or witi an #[if[-r,ii y r1t"r 1td.rd. Thb Facrity stta nd b€ tisu€ ror |he toes of or rramago lo3nyp€€ona|p.op€rtyinc|udirE.Mno|[dt€dtomon6y,c.ed|tcalds.c|othing,ii'*liy.ir"o."v-nr.*,de0ia|d€vic€s,h€adngaids,furs,docrJsqan

Yoursigna!uleonlhisdocu'n€ntfU|vaUlhoriz€s.ourslaf8doc1orslo.per'ormeny€xaminations,diagno6tic|esls&/orlretmentasw6meycon.ide.med&?tvn€ce9r&lore|6asga||in'o'ma|ionp€dino'i|oyourhealth,iy1"''"'.-*5pr'Lro.."nrf"]iap'pGti"p.,u""onyooroemr.<jui_olri"ij."r"n","".nmidloprdd|nga||p€tjentsr9gard|essofrace,oo|o'.natbna|ofi9in,,:9:|':91d]*bi|il.yo]retigi'.r"-poiiii""tt.tii,r"qualityhea|rnceiese-J'J'iit#ieiwrnoi9nnyanmm'H|Prequkos lhat we have you road & !*n th€ tederally governod Health c6re F u"y [rti"". rti" Noli,e

_b dobil€d on p€ge -3 oa this documont. Th6 Henh ca.€ priyecyNotic6wiNexp|ainwhen'wf6reerd$,hyyoUrconfrd-enrlarparrlirrrormarumaiE,JlJ-"a-cr*"r'a'edendisaparlo||hisdocumen||halis.Panen

medical reco(ls whbh is maintained in ihb ofrce. You may recaive a tree phJdopy Jir,il,io"un,."r rn r you hev€ sign.d iust by &sti.€ on€ of oor staff.YoUrsignatureonthisdocu'nerconlirmsthatyou.l1"9.4'':!.f.1']d3ndag'€€tocomptywitha||ofth6tems&co0diti'nsoftheH€a[hcar6P.ivacyNolicsaa||Po|ioies,consents.lermsaco.ditionsr6s€rding.}our-respon"iuini.olort'i"r*if"naii',i-[u.gonrtt*pt'to,i"ians,lh6lEpiandora||yourconfd6ntia|h€ahhin'orrnalionwi|hClhorshordertotrsatyouand/ofinorcLrtoariarigerorpay'"nrotyou,'ou"noo.r*i',,oii",-n"..t,isFacj|opeia|.onsand responsibiblies Please dir€ct anv questions o'. concern" to a mr.u., or *i"r"n. w" in-'iage questions and/or concernsio avoii'mrsunoerstandings. oflp€ hoursa||ovvourpalienlsconvenienca|osch€duleaoPoinlmesbefole&af;;;ri""*ii""i.,iigL"*r,.ryoumus|missanappointmenlp|eas€nolfyus'|fyo|'/(|onots,lup for your schedul€d appointmenl vou will b€ charg€d g15.oo as a missed

"prpoi"iin-""ii"" t

"r vou must pay b€for€ t,ou a.e seon oi rreated agein. l/!b are atlailabr€ tolmm.dielely s€e ne$' palients the samo dav or lhrough

"- zl.r,orr -,za"y ".Jr!.n"i ilJir t

" ".rrr".y tor you, w6 may ca you on th6 r€rephons whe, an appoiolmontis missed and/ot you h€ve not been in to' iu/hile. lf you do not wish ior uilo c"rr-yo" 6ir"ir y" ,"rrlroer carcs preas€ tet us k|ow in $/ritjng for

',our

filo.

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MCCARTER HEALTE CENTER4315 E[rDRsoN AvE, PARKERSBTTRG, WV 26104 (304) 428_8300

Fax: (304) 428-5087

or symptoms?What caused the problem or symproms to occur?\/Vhen did the problem or symploms begin?Have you seen another docior for this problem?Whal testvprocedures have been performed?Have you had this problem or symptoms in the past?Have you tried any other treatments for this?ls the problem or symptoms getting worse?

lx-Ray I MRI US[J No, lf yes, exptain0 No, lf yes, exptain0 No, lf yes, explain

I Headaches! Blured Msion0 Heart Disease0 Chest CongestionLi PancreatitisD Mid-Back pain! Foot or Ankle pain! Urinary problemsI lrregular Bowels

"nl*gr,l.ltEMs rHArApplyroyou NowAND tN rHE pASr:

3#:|ffi; I'ii,?fi:::*, *,*

E3:"J1,::.' Effiilil?i"f*g {.y l:i" 0 Bteedins Gums n ru"it ijn I s,lJ Gall Slones I Swallc!u'"T' ;;,';;l;Xiff"" Eigi:;PnnT" H;fi:.i;if:'::"U Shortness of Breath I tnegutar_Heart Beat I ffiV/nfOS I A$hma/BronchitisH;ffifiJ:i,gil

r"" or

y,H:i, "and

pain n ro" d..-r.i.in _ r Hier,""7i"g"#,Dsknproorems E;il;f;"""" 9fi":liJff,.fflffJ ll:n:::iim,

What is your occupation?What is your employment slalus?

Do you use lobacco?Do you consume alcohol?Do.you have a history of substance abuse?Ltsl a pasl surgefiesLisl all drug alteruiesList all curent and past medications / drugs

Drug Name:

E I:T"?:. g,Jc eenn oiia uirity

tr Full Time tr part Timetr Unemployed trRetiredLasl Day of Work

tr No trYes Explain:O No trYes Explain:

Lisl all physicians you have seen in the past 5 years?Name

For What?

Family HistoryFather ! LivinoMother 0 Livin;Brother ! Livin;urorner U Livingutster U Livinq

_ Sister D Livin;lJ Other problem(s) not liste-d

ll Deceased - Cause of DeathU Deceased - Cause of Deathll Deceased - Cause of DeathU Deceased - Cause of Death

_U Deceased - Cause of Dealh

! ueceased _ Cause of Death

Age:Age:Age:Age:Age:Age:

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MCCARTER HEALTII CENTER4315 EMERSoN AvE, PARKERSBURq WV 26104

(304) 428-8300FAx: (304) 428-5087

Circle location(s) of your symptoms on body drawing. Outline using the symbols for the type of sensation.

Describe your pain (check all that apply):! ConstantD Intermittent! Recurring! stabbingI Dull AcheI snarp! Deep AcheD ThrobbingI Tingling! While Resting! Daily0 During Exercise! Nightly!

Onset of Pain:I Sudden! Gradual

RqaOnascaleof 1 to 10 how would you rate your pain level? _ ( 1 = Mild, 10 = Intense)

Vvhat if anything gives you relief?

PainNumbness ++++++Burning Il I ll ll ll IAche XXXXXX

fIAUTOACGIDENT Date

Were You

Vehicle Damage

Police Report

Activities

Time _ [am] [pml Location

0 Driver I PassengerI I I realeo tn E.K.!YES !NO

! Unconscious! Wearing a Seat Belt0 Transported by Ambulance I YES i] NOI Minimal - Moderate I Severe - TotaledWas the vehicle towed away? ! YES I NO! None

! No restridions

l-l Yes with Police Dept

I Missed _ days of work or school! | felt fine before the accident

fl Work Relatedor Other lnjury

Date Time _ lamj [pm] LocationDescribe injury and how it happened:

Accident Reported to! No restrictions 0 Missed _ days of work or school! lfelt fine before ihe injury

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on

-(date)

MCCARTER HEAITTI CENTER.{315 EMERSoN AvE, PARKTRSBURG, WV 26104

(304) 428-8300FAx: (304) 428-5087

the doclors, therapisls, slaff and palienl urorking togelher as a leam lo oblain the maximum resulls. Palienl satistaclion is a vilalinleresl to our slaf.This Facility is required by law lo abide by the lerms ot this Health Care Privacy Nolico as !,vell as olher appljcabls federal and slale laws governing privacy

praclices in heallh care. Our Facilit may change ancuor modiiy lhe lerms oflhis Notice at anytime wilhoul additional nolice lo you excepl lo publicv posl in o'rr Facilit and/ormake availablelo palienls any lpdaied notices. Pholocopy oflhis Nolic€ is available to you upon requesl. The term Facility refers lo lhis office or clinic. Thelem Providerr€f€rs lo doclors and/or licens€d professionals of lhb Facility,

Our Facilty & slaff ar€ commitled lo mainlaining the privacy of your protecled health informalion (PHl). PHI js jnformalion about you, including demographicinformalion that may idenliry you snd thal may bs relaled lo your pres€nl, lulure and pasl phlsical or menlal heahh or condilion and lhs csr€ and lre€lmenl you rec€iv6 fromour practice. This Nolio€ describos how medical informafon aboul you may be used and disclosed and how you oan obtain access lo lhis informslion. Please read thisNotice and direct queslions, mbunderstandings or conc€rn lolhe Compliance Oflicer oflhis Fac;lity.

Ctur Facilily rnay us€ A disclose yoor PHI for health care d€livery purpos€s. Your PHI may b€ us€d and/or disclo6€d withoul yout writt€n rulhorization by thedoctors and daff oI this Facility for lhs purpoc€s o[ your care and lrealment; paying your he€lth car6 bills: and to $ppo.l the opralions of ihis praclice. Your doctor and lhestaff will tiake all reasonable measures lo marntain lhe conlidentiality of your PHI-

Th6 Pri\racy Rule allc rs lbu lhe righl lo revie$r and receive copies of your health care Gcords as ;l relales lo your he€llh care. The request musl in ffiling,ellowing your provider 30 daFto respond. Your provider maydeny your reqlest ifil willcaus€ harm lo you orlo anoih€rperson. You. provider may cherg€ a copy fee, whichwlll be in compliance with Slale law. Your pmvider wjll comdy wilh any reasonable request to have contidential communication by allernallve m€ans or al an aliernalivolocalion if not doing so endangers yo!.

You may requesl lo hav€ an amendmenl placed in you| record if you disagree with anything in yolr record. This des nd m€an lhat anything will be removed orchanged and lhe p.ovrder has lhe righl to respond wilh a rebutlal sitalement if he/she f*ls it is necessary. You may revoko aulhorialion, in wiling, al any lime. except in lhe€!€nl lhat th€ providd has acled as indicaled in the doctor\ Auliod2alion No{ice.

You hav€ lhe right lo lile a wntlen complainl with our Cornplianc€ Officar ifyou believe thal any of your privacy rights havs be€n violated. You can oblaln acomplaint form from th€ Compliano€ Officer and/or lhe Offlce of lhe Civil Righls. AII complaints musl be filed wilhin 180 daF of when you knew or should have known lhat lheviolalionoccUrred.ThsPriydcyLawp'ohibitsoUlFacl|ityfrom|akinganyr€laliatorac|ionsagainstanyonawhol]|esacomp|aint.Amorede|ai|ed,upde|&comprehens[eHealth Car€ Privacy Nolice is available for your review in lhis Facilty.

I undeFland that lhis Facilfty. ns doclors & staft are accepting my cas6 b€sed on examination findings & believe lhe oullined lrealrnenl shoold prodoce changeand/or improvemenl, Hoursver as wilh any diagnoslic test. p.oc€dure, €xaminalion or doclors care a gua€ntee of jmFovement or complele recovery cannol be made and it isev6n possibla lhat no chang€ vrill occur,

i furlher und€rsland lhal in lhe praclice o( medicine, ohiropractic, psychological counsel'ng, massag€ the.apy & physical lherapy lhere are some risks includingbulnollimiledtofrac|ures,diskiniuri€s's|roles.dislocaljons.sprajns6lrajns,druginleraclions&rsac1ionsand./olo|horinjuri€sorsidsefeclswhiohoadet€rmined.

I do nol etpecl lhe doclo./provirer lo b€ abl€ lo anticipalo and explain all risks and/or complicati{rns, and I wish io rely on th6 doclor/provider lo €xercise judgmentduring lhe cours€ oJ the procedure(s) wfiich lhe doclor/provid€r f€€ls al th€ liryE is in my b€st interesl.

In addilion. b€.aus€ p6!,cho-social, spidlual, and cuhuralvalues afect a patienl's respons€ lo care. pali€nls ar€ all,ed to erp.€6s and folkr/v spintual boliefs andculloral praclices lhal do nol hsrm others or inlerfer€ with lhe planned cours€ of lr€aIment.

Patients hav€ the righl to refuse lrealm€r . bul musl be a$rar6 of lhe probeble cons€qu€ncss oI .etusing h6€lment andlor failiog lo cooperal€ wilh the prescribodl.ealmenl. Should you refus€ ancyor fail lo comply wilh prescribed lreatment your provlder will dbcuss sp€cifc cons€quonces wilh you.

Therefore I gwe my firll consenl lo tho doctor/provider lo rsnder lreatmenl on me or th6 minor for whom I am l€gaUy r€sponsibl€ by a heallh care provider ol thisFacility.

I, lhe assigne€, b€ing lho patienl or legal guardian for said minor lisl€d b€lorr, do hereby inevocably adhorize. dned. assign and give a full lien lo th6 offic€nsmedaboveand|isledbe|o/v,h€reinaferreferrsdtoasthe"Faci|Magainstanyaa|nsuranceb€ns|its'proc€€dsofanys€tl|ern€nl,jUdgm€nto'verdic,lwhichmaybe|dlo lh€ unde.sigaed as a regrlt of lhe injuries or illness for which lhav6 been lrealed by the Facilily.

l, the asslgne€ furlher aulhorizes any and all insorance company, atlomoy and €ny A aI $ird parly payer lo pey directly to lhe Facility allsums of ftoney due th€mlor any & all servic€s rendered lo me or minor by whom I am responsible for by reason oi accidenl, illoess and by any & all .e?son of any olher bills lhal are due or rneybecome due, and lo wilhhoid such sums from any heallh & accident, $orlers compensalion and or including all irBurance o. third p€rty b€n€f|ts.

Assign€o agtees lhat lhis Fadlity & staf may deliver medical records. conssllations, depogitions and/o. court appearanc€s which must b6 peid in JUI in advan6eandaUthorizesthisFei|dytore|eas€anyin'ormationPer|inenllosaidhe|lhcareloanyinsurancecomPsny,adj6|e.'attorn€yor|eg€|seric€bureautofaci|ilateco|hsunder lhe tems of this dopumenl. Assignee granls lhe Facilily a full poa,Er o{ atlorney lo endoas€ a,/or sign rny name on any a aI checks foa paymenl of any indebtedness

will obtain a payerscoverage and liability. Our Facilfty A daff 3re nol responsible a lhird parly peyer and/or represenlalave may lell u€. Any coriraclual. witlen, veabal or otherobligaljons or arangemenls b€ii,esn you and an atlofney, insurance company, liab'e or third party pa',e. are bd\ reen you and said pers{,n,I . Our Facilily will file inifal insurance claims for you. Secondar claim submission and/or addilional reports or documenls sent for your benefrt may result in an additional

filing or medical report char96s, whlch you ar6 responsiblelo pay.2. Co-paF, deducribbs and sll noo-cov€red s€Nice charges are du6 lhe day lhe seryic6 is rendered.3. Patienls are r€sponsible {o. charges on all s€rvice(s) ando. p.oducl(s) which may oxceed th6 maximum allo$rebl6 end/or when a third party and/or insurance oafii€r

does nol reimbutse lhis Facjlily enough lo m€et our cod ot service.4,Al|accounlba|ances,indudingado.nobi|€and\i/orkjnjuryc|aitrmustbepaijinfu|lwilhin90daysofif€lment,hienlsarefuI|yrespoosiue'ora||mone'o\lhjs

office and such paynenl is nol contingenl on eny ssnbmenl, clalm, iudgmenl, or verdicl by which th€y may evenlually recover said fee and it is also regardless of anyatiomey liens or Pnding senlement(s). fa third party payer fails to p3ysaid balanc€ in fullv,,ilhin lhe 90iay period,lhe palient musl payth€ balance in full. Asegneeis fully responsible for all money o/\,ed this Facility for any and all lreatrn€nl, producls & se.vices rendered to the palienl or minor sho$rn below-

5. A noniascriminelory'Tim€ of Service Discount" is offe.ed to anyone wio paF for services the day lhey are rendered. Tbe 'TOS" b ont ofiered on the day the servjceis rendered. This discouot does not apply to orthopedic supFrts, ortholics. phFical therapy equipment reilals or purchas€s, vilamins, supplements, oinlmenls.acupunclur€ lnealmenls, weigi loss programs, psychologbal counseling s€rv|_ces and massge th€rapy.A service charge as comp'ied by a 'pedodic ral€'of 1N % per monlh - 18% p€r annum & is added to all balances o,ed 60+ daF. Any balance p€sl due 90 days ormore may be submifled 1o an atto.ney and/or agency for legal collectjon for whioh the undersigned agrees io b€ 100% responsible for all monthly service charg€s,interest, co6ls relaled 1o bul nol limiled 10 allcollection relaled expenses, atlornoyfees, court & tilinq te6's. Relurned checks. debil & credil charq€s made payablelo lhis10 allcollection retaled expenses, atlornoyfees, court & tiling te6's. Relurned checks, debil & credil charg€s made payablelo lhis

enls or other reasons of non-paymeot will b€ assess€d a $30.00 charqe.Facility for insufticieri Iunds, slop paymenls or other reasons of non-paymeot will b€ assess€d a 930.00 charge.credil & debit

8y my signalure belo{ lacknowledge lhal I have read or have had read to me and hav6 received a photocopy upon my requ€st of this documenl including lhe Health CarePrivacy Nolice, Facilily le.ms & condilions, credil policies and lnform6d Consenl and fully understand and have had allof my questions answered lo mysatisfaclion. Apholocopy oflhis documeot shall be coosidered as effectiv€ and valid as an originat_

Prinl Name of Palienl

!Signature (if minor, parent must sign) Date