Schedule Appointment | Chiropractors In Florida

Jupiter:
(561) 744-7373
Palm Beach Gardens:
(561) 630-9598
Port St. Lucie:
(772) 337-1300

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Meet Dr. Papa

Jupiter:
(561) 744-7373
Palm Beach Gardens:
(561) 630-9598
Port St. Lucie:
(772) 337-1300

Home
New Patients
About Us
Services
Locations
Community Content
Blog

Meet Dr. Papa

Busy? fill out these online forms and save yourself 20 minutes!

GENERAL INFORMATION

Patient LAST name*

FIRST name*

Phone *

Phone (C)

Address

Care of

City

State

DL #

No. Children

Out of State Address

Spouse's Name

Spouse's Employer

Native Language

Email Address

Sex

Male Female

Status

Married Single Widowed Divorced

DOB

SS#

Employer's Name:

EMPLOYED

Full Time Part Time Retired Unemployed

Employer's Address

City

State

Zip

Phone

Occupation

STUDENT

Full Time Part Time Non-Student

INSURANCE INFORMATION - Commercial Insurance and Medicare Only

PRIMARY Insurance Company

Type

Group

Private

Membership/Cert #

Policy Group #

Complete only if Patient is NOT the Insured Insured's Information:

Insured's Information

Insured's Name

Sex

Male Female

Status

Married Single Widowed Divorced

Patient Relation to Insured

Insured's DOB

Insured's Employer

SECONDARY Insurance Company

Type

Group

Private

Membership/Cert #

Policy Group#

Complete only if Patient is NOT the Insured

Insured's Information

Insured's Name

Sex

Male Female

Status

Married Single Widowed Divorced

Patient Relation to Insured

Insured's DOB

Insured's Employer

AUTOMOBILE ACCIDENT/ WORKER'S COMPENSATION

Insurance Company

Claim #

Policy #

Address

City

State

Zip

Phone Number

Date of Injury:

Attorney's Name

Phone Number

Address

Contact Name

Release and Assignment

I authorize release of any information necessary to process my insurance claims and assign and request payment directly to my physicians.

Patients Signature:

Date

Michael Papa D.C., P.A.

2632 West Indiantown Road
Jupiter, FL 33458
Phone: 561-744-7373 Fax: 561-743-1192

ASSIGNMENT OF BENEFITS

I, the undersigned patient, hereby assign my Personal Injury Protection insurance benefits under my policy of automobile insurance or all other applicable Private policies benefits under my medical insurance, for all causes of actions to MICHAEL PAPA D.C., P.A., its subsidiaries and its agents, including but not limited to MICHAEL PAPA D.C., P.A., for services rendered to the undersigned patient in accordance with Florida Statue 627.736(5), that would otherwise be payable to me for services rendered.

I fully understand that by the execution of this assignment of benefits, that I also grant MICHAEL PAPA D.C., P.A., its subsidiaries and its agents including but not limited to MICHAEL PAPA D.C., P.A., full power of attorney and authority to act in or on my behalf insofar as the endorsing and cashing of checks as well as the execution of any other documents that may be related to this matter or claim. I agree to be fully responsible for the services provided regardless of settlement, judgment or verdict. I further direct my Private insurance carrier to provide any medical provider with an updated copy of the PIP Payment Log. A photocopy of this document shall be as binding as the original signature page.

PATIENTS/INSURED SIGNATURE

INSURANCE COMPANY

DATE

DATE OF ACCIDENT (If applicable)

FINANCIAL POLICY AGREEMENT

We are committed to providing you with the best possible care. If you have medical insurance, we are eager to help you receive maximum allowable benefits. In order to achieve these goals, we need your assistance, and your understanding of our payment policy.

Payment for services is due at the time services are rendered unless our staff has approved payment arrangements in advance. We accept CASH, CHECK, MASTER, DISCOVER, AMERICAN EXPRESS, or VISA CARDS. We will be happy to help you process your insurance claim-form for your reimbursement.

Returned checks and balances older than 30 days may be subject to additional collection fees and interest charges of 1.5 % per month. We will gladly discuss your proposed treatment and answer any questions relating to your insurance.

You must realize, however that:

1. You insurance is a contract between you, your employer and the insurance company. We are not a party to contract.

2. Our fees are generally considered to fall within the acceptable range by most companies and therefore are covered up to the maximum allowance determined by each carrier. This applies only to companies who pay a percentage (50% or 80%) of "U. C.R." a. "U.C.R." is defined as usual, customary and reasonable. This statement does not apply to companies who reimburse based on an arbitrary "schedule" of fees, which bears no relationship to the current standard and cost of care in this area.

3. Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover.

We must emphasize that as medical providers, our relationship is with you and not with your insurance company. While filing of insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date the services are rendered. We realize that temporary financial problems may affect timely payment of your account.

If such problems do arise we encourage you to contact us promptly for assistance in the management of your account. If you have any questions about the above information or any uncertainty regarding insurance coverage PLEASE do not hesitate to ask us. We are here to help you.

PATIENTS/INSURED SIGNATURE

INSURANCE COMPANY

DATE

DATE OF ACCIDENT (If applicable)

PRIVACY PRACTICES ACKNOWLEDGMENT

Posted on Lobby Wall

ACKNOWLEDGEMENT FORM

I have received the Notice of Privacy practices and I have been provided an opportunity to review it.

NAME

BIRTHDATE

SIGNATURE

DATE

WAIVER

I acknowledge that I was given the opportunity to accept the Notice of Privacy Practices and have chosen not to receive that Notice or have it explained to me

NAME

BIRTHDATE

SIGNATURE

DATE

QUADRUPLE VISUAL ANALOGUE SCALE

INSTRUCTIONS: Please put a mark on the line that best describes the question being asked.

NOTE: If you have more than one complaint, please answer each question for each individual complaint and indicate the score for each complaint, Please indicate your average pain levels and pain at minimmum/maximum using the last 3 months as your reference. If you have completed this form before, indicate you average pain level since the last time you completed this form

EXAMPLE:

0 - No Pain
1 - Headache
2 - Neck
3 - Low Back
4 - Worst Possible Pain

1. What is your pain RIGHT NOW?

2. What is your TYPICAL or AVERAGE pain?

3. What is your pain level AT ITS BEST?

What percentage of your awake hours is your pain at its best?

4. What is your pain level AT ITS WORST?

What percentage of your awake hours is your pain at its best?

SCORE:#1_____+#2______+#4_________=________ /3 x 10 =____________ (Low intensity = <50: High intensity = >50)

Papa Chiropractic and Physical Therapy

2632 W Indiantown Road
Jupiter, FL 33458

(561) 744-7373
(561) 743-1192 Fax

RELEASE OF RECORDS

Date

To (Doctor or Hospital)

Address

I hereby authorize and request you to release my complete medical records, concerning my illness and/or treatment during the period

To:

Papa Chiropractic and Physical Therapy

2632 W Indiantown Road

Jupiter, FL 33458

(561) 744-7373 (561) 743-1192 Fax

Name

DOB

Date

Signed: (Signature of patient/guardian, if patient is a minor.)

Medical History Questionnaire
(Confidential Information)

Patient's Name

Date

Reason for Visit

MEDICAL HISOTRY: Please circle the following

High Blood Pressure

Yes No

Skin Disease

Yes No

Bleeding Disorder

Yes No

Thyroid Disease

Yes No

Anemia

Yes No

Lung Disease

Yes No

Liver Disease

Yes No

Tuberculosis

Yes No

Heart Disease

Yes No

Shortness of Breath

Yes No

Psychiatric Illness

Yes No

Hepatitis

Yes No

HIV

Yes No

Diabetes

Yes No

Please list any other medical history the doctor should be aware of:

Please list any prior hospitalizations below (ie, accidents, etc)

FAMILY HISTORY: Please give the age of living or age and cause of death.

Father

Mother

Siblings

Children

MEDICATIONS: Please list medications you currently take, including appetite suppressants, vitamins, herbal supplements„ or any homeopathic medication:

Do you take any Aspirin or any Aspirin- containing compound?

If "Yes", for what reason?

Do you have any ALLERGIES and/or SENSITIVITIES? (Please indicate which, if any, are present)?

Penicillin

Yes No

Aspirin

Yes No

Sulfa

Yes No

Xylocaine

Yes No

Any other Antibiotics

Yes No

Adhesive Tape

Tetanus Toxic

Any other

SOCIAL HISTORY

Cigarette Smoking

Yes No

How long since last use?

Alcohol Use

Yes No

Drugs

Caffeine

None Daily

How much?

Do you take Vitamin E?

Yes No

If "Yes," how much?

SURGICAL HISTORY

Please list all previous surgeries/operations, as well as cosmetic:

Date

Please list all previous surgeries/operations, as well as cosmetic:

Date

Please list all previous surgeries/operations, as well as cosmetic:

Date

Please list any complications or problems you experienced during or following the above procedures

Do you wear corrective eye glasses or contacts?

Date of last opthalmology (eye) check up?

Have you recently been under the care of a physician for any reason?

Yes No

If Yes, please explain

Family Physician

Date of last check up

Address

Phone

Note: if you are scheduled for surgery at any time, please be advised that you cannot take aspirin or aspirin-containing products for a period of two weeks prior to your surgery. Evidence suggests that even small amounts of aspirin or other anti-inflammatory products can create bleeding problems in the apparently healthy adult. Acetaminophen, such as Tylenol, may be used as a substitute for aspirin.

Papa Chiropractic and Physical Therapy

2632 W Indiantown Road

Jupiter, FL 33458

(561) 744-7373

X-RAY CONSENT FORM & PREGNANCY RELEASE IF APPLICABLE

Patient Name

Patient Date of Birth:

PLEASE ANSWER THE FOLLOWING QUESTIONS:

FEMALE ONLY 1-4

1. Are you pregnant or any chance you may be

Yes No

2. Date of the start of your last period

Yes No

3. Are you on any type of Birth Control?

Yes No

4. Are you trying to get pregnant?

Yes No

Your signature indicates that you have read, understood and answered all of the above and accept all responsibility associated with exposure to yourself or your unborn child and have accurately answered the above statements.

Signature

Date

Witness

Date

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

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Name*

Email *

Phone *

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

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Visit our Office

--mi

Address

2632 W Indiantown Rd
Jupiter, FL 33458

Contact Information (561) 744-7373

(800) 783-5176

[email protected]

Schedule Appointment

-- mi Jupiter
-- mi Palm Beach Gardens
-- mi Port St. Lucie

Regular Office Hour

Jupiter

Monday

8:00 am - 12:00 pm

2:00 pm - 7:00 pm

Tuesday

2:00 pm - 7:00 pm

Wednesday

8:00 am - 12:00 pm

2:00 pm - 7:00 pm

Thursday

8:00 am - 12:00 pm

Friday

8:00 am - 12:00 pm

2:00 pm - 7:00 pm

Saturday

8:00 am - 12:00 pm

Sunday

Closed

Palm Beach Gardens

Monday

8:00 am - 12:00 pm

2:00 pm - 7:00 pm

Tuesday

8:00 am - 12:00 pm

Wednesday

8:00 am - 12:00 pm

2:00 pm - 7:00 pm

Thursday

2:00 pm - 7:00 pm

Friday

8:00 am - 12:00 pm

2:00 pm - 7:00 pm

Saturday

Closed

Sunday

Closed

Port St. Lucie

Monday

8:00 am - 12:00 pm

2:00 pm - 7:00 pm

Tuesday

2:00 pm - 7:00 pm

Wednesday

8:00 am - 12:00 pm

2:00 pm - 7:00 pm

Thursday

8:00 am - 12:00 pm

Friday

8:00 am - 12:00 pm

2:00 pm - 7:00 pm

Saturday

Closed

Sunday

Closed

Busy? fill out these online forms and save yourself 20 minutes!

ASSIGNMENT OF BENEFITS

FINANCIAL POLICY AGREEMENT

PRIVACY PRACTICES ACKNOWLEDGMENT

Posted on Lobby Wall

ACKNOWLEDGEMENT FORM

WAIVER

QUADRUPLE VISUAL ANALOGUE SCALE

Papa Chiropractic and Physical Therapy

RELEASE OF RECORDS

Medical History Questionnaire
(Confidential Information)

Papa Chiropractic and Physical Therapy

Get Back in the Game!

Sign up for our newsletter.

Visit our Office

Regular Office Hour

Jupiter

Palm Beach Gardens

Port St. Lucie

Jupiter, FL

Palm Beach Gardens, FL

Port St. Lucie, FL

Busy? fill out these online forms and save yourself 20 minutes!

ASSIGNMENT OF BENEFITS

FINANCIAL POLICY AGREEMENT

PRIVACY PRACTICES ACKNOWLEDGMENT

Posted on Lobby Wall

ACKNOWLEDGEMENT FORM

WAIVER

QUADRUPLE VISUAL ANALOGUE SCALE

Papa Chiropractic and Physical Therapy

RELEASE OF RECORDS

Medical History Questionnaire (Confidential Information)

Papa Chiropractic and Physical Therapy

Get Back in the Game!

Sign up for our newsletter.

Visit our Office

Regular Office Hour

Jupiter

Palm Beach Gardens

Port St. Lucie

Jupiter, FL

Palm Beach Gardens, FL

Port St. Lucie, FL

Medical History Questionnaire
(Confidential Information)