Jacob D. Gill D.C.

1722 N. Plum

Hutchinson Kansas 67502

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Referrals

Where did you hear about us? Circle as many as apply

Feist Area-wide Radio SWTB

Spinal Screening Personal Reference

The ten days following the onset of the menstrual period are generally considered safe for x-ray examinations.

Onset of last menstrual period. Date: Date today:

I am pregnant Yes No Maybe

I have had a hysterectomy Yes No

AUTHORIZATION TO RELEASE INFORMATION: I authorize Gill Chiropractic& Acupuncture, to release any medical information that may be necessary for either medical care or processing of insurance benefits.

ASSIGNMENT OF INSURANCE BENEFITS: I authorize direct payment of all insurance benefits to Gill Chiropractic & Acupuncture for services rendered. I understand it is my responsibility to know the extent of coverage and limitations under my insurance policy, including precertification and guidelines. I understand that I am financially responsible for the balance not covered by insurance.

CONSENT FOR TREATMENT: I authorize all medical treatment prescribed by Dr Jacob D. Gill or his designee. I understand that no guarantees have been made as a result of treatment or examination.

ONE TIME AUTHORIZATION: I request that payment of authorized Medicare benefits be made on my behalf to Gill Chiropractic & Acupuncture for services furnished to me by Dr. Jacob D. Gill. I authorize a holder of medical information about me to release to the Health Care Financing Administration and its agents, information needed to determine these benefits or the benefits payable for related services.

Consent to X-ray: I hereby authorize Gill Chiropractic and Acupuncture and whomever the doctor may designate as his assistant(s) to take x-rays of myself or my minor child