Patient Information

Health Review

Please check all the conditions you have or have had

Pain Relief Center - Symptom Assessment

NECK, BACK, EXTREMITIES Check all current symptoms: Please Select R for right and L for left

NECK

SHOULDERS

MID-BACK

ARMS & HANDS

LOW BACK

HIPS, LEGS, & FEET

Financial Agreement

I (we) agree to pay for services rendered for the above mentioned patient as the charge is incurred. I understand and agree that health and accident insurance policies are an arrangement between the insurance carrier and myself and that I am personally responsible for payment of any and all services covered or non-covered. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered me will be immediately due and payable. Notice to our new patients: Please understand that this office does NOT accept insurance as payment for care. Full payment for services rendered is due at the end of each visit, however, we are more than willing to complete your insurance forms so that you will be reimbursed by your insurance carrier. If for any reason this request cannot be met, arrangements must be made in advance before seeing the doctor for treatment.

Neck Pain Assessment

Headache Assessment

Facial Pain Assessment

Show the location of your neck head and facial pain by marking the diagrams below

VITA HEAD, NECK & FACIAL PAIN RELIEF CENTER

Louis R. Vita, D.D.S., Angelo Colavita, DC, BCAO
991 Van Houten Avenue Clifton, NJ 07013

I hereby authorize Dr. Vita and/or Colavita to examine me and suggest additional diagnostic testing. I understand that a patient seeking treatment at our office gives consent to his doctor to provide care in accordance with tests, analysis and diagnosis. It is rare that adjustments or other clinical procedures cause any problem, however, underlying physical defects, deformities and pathologies may render the patient susceptible to injury. The patient is responsible to truthfully disclose all pertinent information to the treating doctor regarding any illnesses, injury or adverse physical condition from which he/she is suffering or has experienced in their medical/dental history. While the doctor may advise the patient to seek diagnosis and treatment for a non-related condition, it remains the sole responsibility of the patient to do so.

The doctor and/or staff have advised me that this treatment regimen must be strictly followed. I agree that the doctor may terminate the doctor/patient relationship if he determines that I have not followed or am unlikely to follow the treatment regimen completely as it is critical to the success of my treatment. In the event that I am dismissed from care, or I, myself end treatment, it becomes my sole responsibility to seek and find treatment or further diagnostic testing from other healthcare providers. I will not hold the office of the Vita Head, Neck & Facial Pain Relief Center liable in any way whatsoever for such discontinued treatment or lack of follow up to another physician.

Neither the doctor nor any member of his staff has made any guarantees that his treatment will cure or benefit me in any way. I release the Vita Pain Relief Center, Dr. Louis Vita, Dr. Angelo Colavita and their staff and heirs from any and all claims and damages arising out of my treatment or omission to treat and diagnose, treatment outcome, or any aspect of care and result or lack thereof. I fully agree that I will not make any negative or disparaging comments about any or all parties and care heretofor rendered. This includes written and verbal actions or comments.

I consent to have Dr. Vita/Dr. Colavita evaluate all of my available records and discuss with my physicians and dentists all past information that will assist in my care. I authorize Dr. Vita and/or Dr. Colavita to disclose any and all pertinent information to other healthcare providers and any other individual for my benefit within the confines of the Federal Privacy Practices Law. A copy of the Federal Privacy Practices Law is available at the office and will be furnished to me upon request at any time.

I give my permission to the doctors to share information about my case with other researchers as needed for statistical purposes and for possible science publication in medical journals. I also agree that my health information may be shared with governmental and/or regulatory agencies. I give my permission to Dr. Vita and/or Dr. Colavita to present my case, diagnosis and treatment outcome for teaching purposes and to include non-identifying photographs in presentation. I understand that in any publication, specific identifying information such as names and addresses will not be used. (Patient's initials required).

This office does not participate in any insurance plan other than Delta Dental for its dental patients only. Therefore payment will be made at the time of the service. Insurance reimbursement is solely and contractually between my insurance company and me. This office makes no claims of reimbursement from any insurance carrier for services rendered by the doctors. Payment for all services remains my sole responsibility and I agree that if I continue to have an outstanding balance, legal action will be taken to collect the fees due.

I authorize the release and transmission of my medical records as required by my insurance company in order to process claims. I authorize this office to receive and accept payment directly from my insurance carrier in the event that I have not paid at the time of the service. I understand that my insurance will be filed by me and for my benefit only. This office does not guarantee reimbursement for any services rendered since this practice does not participate with my insurance plan.

I have read, understand and willingly consent by my signature below.

With my permission, Dr. Louis Vita and/or Dr. Angelo Colavita may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Please refer to Dr. Louis Vita's Notice of Privacy Practices for a more complete description of such uses and disclosures.

I have the right to review the Notice of Privacy Practices prior to signing this consent. Dr. Louis Vita and/or Dr. Angelo Colavita reserve the right to revise the Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to the Privacy Officer.

With my permission, the office of Dr. Louis Vita/Dr. Angelo Colavita may call my home or other designated locations and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results among others.

With my permission, the office of Dr. Louis Vita/Dr. Angelo Colavita may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Dr. Louis Vita and/or Dr. Angelo Colavita restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this, I am allowing Dr. Louis Vita and/or Dr. Angelo Colavita to use and disclose my PHI for TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent.

Release of Information

This information may be released to:

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