Indianapolis Pain and Wellness Center

Welcome to our office!

Please fill out our Health Record as completely and accurate as possible. If you have any questions, please don't hesitate to ask one of our qualified Chiropractic Assistants. It is our pleasure to be of service to you. Our commitment to you is to promote the highest quality of health and well-being with Chiropractic care. 

Employer Information

Emergency Contact

What type of complaint?*
Please select at least one option
How did this injury or condition occur?*
Please select one option
What is frequency of pain?*
Please select one option
What is quality of discomfort?*
Please select at least one option
If the discomfort radiates, where does it travel to? Otherwise, choose NON-RADIATING.*
Please select at least one option
Is complaint getting better, worse or staying the same?*
Please select one option
What is the VAS? Rate your pain on a scale of 1-10 (10 being worst)*
Please select one option
What is symptom relieved by?*
Please select at least one option
What aggravates the symptoms?*
Please select at least one option
Any past episodes of this complaint?*
Please select one option
Has patient received any past care for this complaint?*
Please select at least one option
Have any recent diagnostic images or tests been performed?*
Please select one option
What activity of daily living most affected?*
Please select at least one option
What does patient have difficulty performing due to this specific complaint? (Choose all the apply)*
Please select at least one option
What were the patient's specific therapeutic goals?*
Please select at least one option
Is there a 2nd complaint?*
Please select one option
Has patient denied all of following Musculoskeletal conditions?*
Please select at least one option
What neurological conditions were denied?*
Please select at least one option
What Head and ENT issues are reported?*
Please select at least one option
What cardiovascular issues are reported?*
Please select at least one option
What respiratory issues are reported?*
Please select at least one option
What gastrointestinal issues are reported?*
Please select at least one option
What genitourinary issues are reported?*
Please select at least one option
What endocrine issues are reported?*
Please select at least one option
What dermatological or hematopoietic issues are reported?*
Please select at least one option
What allergy or sensitivity issues are reported?*
Please select at least one option
Patient's surgical history?*
Please select at least one option
Drugs and medication(s)?*
Please select at least one option
Name past illnesses?*
Please select at least one option
Past history of accidents or trauma?*
Please select at least one option
Patient's Immediate Family Health History?*
Please select at least one option
Type of Work?*
Please select at least one option
Type of social habits?*
Please select at least one option
Type of exercise routine?*
Please select at least one option
Type of diet and nutrition?*
Please select at least one option

FOR WOMEN ONLY:

Financial Policy

Insurance Coverage

Your insurance is an agreement between you and your insurer, not between your insurer and this office. Coverage for chiropractic and therapy services varies from insurer to insurer and plan to plan. Most insurance policies require the beneficiary to pay a co-insurance, co-payment, and /or deductible. For example: if you have a deductible of $100, and your insurance pays 80%, you are responsible for 20% of all charges incurred during the year after you have paid your $100 deductible. Our office will call your insurer to verify your benefits, however, this is NOT a guarantee of payment from your insurer.

Payments

In order to help you determine your responsibility toward your payment for services, please read the following, and initial your preference for the method of payment of your account. Please notify this office if the status of your insurance changes.

Private Pay: (please initial)

Who should receive bills for payment on your account?*
Please select at least one option

Time of Service Fee Schedule and Financial Policy

Service Fee

Consultation

No Charge

Initial Exam/

$100-$165

Re-Exam

$50-$120

Adjustments

$39-46



Important: All clients are responsible for full payment for the first visit (unless other arrangements have been made in advance.)

Today's payment will be made by:*
Please select at least one option

Missed Appointments

At the Indianapolis Pain and Wellness Center we do not cluster or double book. The appointment time schedule is yours and your time alone. We also take pride in keeping to schedule. Forgotten and otherwise missed appointment have a serious impact on the office and patients who otherwise could have been seen at that appointment time.

It is our policy of Indianapolis Pain and Wellness Center to assess a $25 missed appointment fee for chiropractic services to patients who cancel within 4 hours before their appointment, and a $50 missed appointment fee for massage therapy to patients who cancel appointments with less than a 24-hour notice.

I understand that all health services rendered to me and charged to me are my personal financial responsibility. I understand and agree to the conditions in this policy. I fully consent to receiving treatment from any or all practitioners in this practice.

Credit Card on File Policy

Indianapolis Pain and Wellness Center is committed to reducing waste and inefficiency by making our billing process as simple and easy as possible. Starting August 23, 2023, we now require that you provide credit card on file with our office. We run our payments through our HIPPA -compliant credit card processor, Fortis. To set up the card on file, we will scan your card with a card reader. Your payment information is stored on Fortis' secure servers for future transactions. Office personnel will not have access to your card information. For your protection, only the last four digits of your card will be shown in our system.

Credit card on file will be used to settle patient balances. These balances may be settled as soon as the amount becomes payable whether that is for services performed that day, a copay due for services that day, or we have received and processed an EOB from your insurance company assigning any cost to you. Credit card on file will also be used to refund any overpayments on your account and will be issued the day the overpayment is established unless other arrangements are made. Payments or refunds due in amounts less than $10 may not be processed if you are an active patient under regular care.

During the time you leave a credit card on file, if it expires or otherwise becomes uncollectible, we will ask you to promptly provide a new means of payment.

You are not required to use the credit card to make payments. You may arrange to pay with cash, check, a different credit card or in certain circumstances request a payment plan.

If a payment is processed in our office when you are not present you may request we text or email you notification of the charge to the phone number or email address we have on file. If we do not have permission to text or email you this information you may request a monthly statement mailed to you.

I request _______ each time my card is processed.

My Health Insurance


I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself . I understand that the Doctor's Office will provide any necessary reports and forms to assist me in collecting from the insurance company and that any amount authorized to be paid directly to the Doctor's Office will be credited to my account upon receipt.


ABOUT THE INSURED PERSON

Authorization for Care:

I hereby authorize the Doctor to work with my condition through the use of adjustments to my spine, as he or she deems appropriate.I clearly understand and agree that all the services rendered to me are charged directly to me and that I am personally responsible for all payment. I agree that I am responsible for all the bills incurred at this office. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. I also understand that if I suspend or terminate my care, any fees for professional services rendered to me will become immediately due and payable. I hereby authorize assignment of my insurance rights and benefits (if applicable) directly to the provider of services rendered.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES 

I have been given a copy of (Indianapolis Pain and Wellness Center)'s Notice of Privacy Practices ("Notice"), which describes how my health information is used and shared. I understand that (Indianapolis Pain and Wellness Center) has the right to change this Notice at any time. I may obtain a current copy by contacting Indianapolis Pain and Wellness Center/Security Official, or by visiting the (Indianapolis Pain and Wellness Center) web site.

My signature below acknowledges that I have been provided with a copy of the Notice of Privacy Practices:

Consent to be contacted by Email or Text

hereby consent and state my preference to have my physician, Dr. Mary Jo Johnson, and other staff at Indianapolis Pain and Wellness Center communicate with me by email or standard SMS/text messaging, in addition to or to replace leaving phone messages, regarding various aspects of my health care, which may include, but shall not be limited to, test results, appointments, and billing.

I understand that email and standard SMS/text messaging are not confidential methods of communication and may be insecure. I further understand that, because of this, there is a risk that email and standard SMS/text messaging regarding my medical care might be intercepted and read by a third party.

I give my permission to leave both appointment reminders AND my private health information at the following (please fill in the ones you agree to):

I give permission to contact me, relative to appointment reminders only, by the following methods:

Thank you for taking the time to fill out this form.

Hours of Operation

Monday

7:00 am - 6:00 pm

Tuesday

7:00 am - 6:00 pm

Wednesday

7:00 am - 6:00 pm

Thursday

7:00 am - 6:00 pm

Friday

8:00 am - 3:00 pm

Saturday

Closed

Sunday

Closed

Monday
7:00 am - 6:00 pm
Tuesday
7:00 am - 6:00 pm
Wednesday
7:00 am - 6:00 pm
Thursday
7:00 am - 6:00 pm
Friday
8:00 am - 3:00 pm
Saturday
Closed
Sunday
Closed

Our Location

Contact Us

We look forward to hearing from you