seminar notes 2017 - hbtinstitute.com

Seminar Notes Table of Contents Lecture: Ethics & Law (2 hours) Billing, Coding & Record Keeping (4 hours) Lecturer: Steven C Eggleston, DC, Esq. 2601 Main St. Suite 800 Irvine, CA 92614 Voice (877) 424-4765 Facsimile (877) 883-2963 www.hbtinstitute.com Page 2 BCE Disciplinary Actions December, 2017 Page 3 BCE Rules & Regulations §302 (Scope of Practice) Page 4 BCE Rules & Regulations §311 (Ads) & §312 (Illegal Practice) Page 6 BCE Rules & Regulations §312 (Ownership) & §314 (Reporting) Page 7 BCE Rules & Regulations §316 (Respondeat Superior) & §317 (Conduct) 0 BCE Rules & Regulations §318 (Accountable Records/Billings) Page 11 BCE Rules & Regulations §319 (Free Services & Informed Consent) Page 12 Notice regarding SOAP Notes (Board rules regarding ethical record keeping) Page 13 How to Write SOAP Notes Page 14 Proper Billing for 1st Week, 1st Month & Re-exams Page 17 Common CPT Codes & Fees Page 19 How to Use HBTI Paperwork Page 21 Collecting Your Professional Fees From All Patients Page 22 Substitution of Attorney Page 23 California Auto Insurance Page 24 Patient Information Page 25 HIPPA Compliant Authorization for Release of Health Information Page 27 Symptoms Page 28 Sintomas (1st page only) Page 29 Neck Area Consultation Page 31 Upper Back Area Consultation Page 32 Low Back & Pelvis Area Consultation Page 33 Shoulder Consultation & Examination Page 34 Knee Consultation & Examination Page 35 Diagnosis (Initial Encounter ICD-10) Page 36 Treatment Plan Page 37 Acute Concussion Evaluation (ACE) Page 38 Epworth Sleepiness Scale (ESS) Page 39 Rivermead Post-Concussion Symptoms Questionnaire (RPQ) Page 40 Assessment of Reactions to a Stressful Car Accident (PTSD) Page 41 Folstein MMSE (Copyrighted Form – For Educational Use ONLY) Page 42 Symptoms Update Page 43 Head Injury Follow Up Questionnaire (HIF) Page 44 Rivermead Head Injury Follow Up Questionnaire (RHFUQ) Page 45 Head Injury Outcome Assessment (HIO) Page 46 Duties Performed Under Duress at Work and Home Page 47 Loss of Enjoyment of Sports, Hobbies, Travel, Daily Activities & School Page 49 Sample PI Narrative (for use if you use the HBTI forms taught here)

HOW TO WRITE SOAP NOTES

IF you are using all 4 forms (Symptoms, Exam, Diagnosis, Treatment Plan) then you may

significantly abbreviate your DAILY SOAP notes using the legal doctrine called “Incorporation

by Reference.”

S: Symptoms Form from 2/4/2017 O: Exam Forms from 2/4/2017 to 2/6/2017 A: Diagnosis Form dated 2/6/2017 P: Treatment Plan dated 2/6/2017 ‐‐‐or‐‐‐ 2/7/2017 See SOAP notes done 2/4/17 to 2/6/17 You may also use your daily SOAP notes to add in the word “because” 3 times to explain WHY

you are doing what you are doing.

Example: I referred this patient to neuropsychologist today because she still has

concussion symptoms after more than 30 days since the accident, they are

not resolving on their own and I want a specialist to examine this patient’s

brain concussion.

Example: I ordered a video fluoroscopy today because my plain film stress x‐rays

revealed joint laxity that can only be caused by torn neck ligaments. I can

only see 4‐8 lax ligaments on plain films and fluoroscopy can see 22

ligaments and I want to see if there are any more torn neck ligaments.

Example: I ordered an MRI today of the cervical spine because the patient has

constant radiculopathy (24 hours a day) in her left upper extremity and

that sign frequently means there is a herniated disk pressing on a nerve

root.

Example: I ordered a video fluoroscopy today because the patient’s radiculopathy is

intermittent (comes and goes) and that sign often indicates torn neck

ligaments. Only when the hypermobile joint slides and bone smashes into

the nerve root does this patient have short‐lasting numbness and tingling.

Video fluoroscopy is the best test to visualize all 22 cervical ligaments and I

ordered this test because I believe this mechanism is the cause of the

patient’s intermittent nerve radiculopathy in her arm.

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1st Week Proper Billing for Patient

1/1/2014 99201 Emergency telephone consultation with patient $1/6 hour

1/2/2014 99203 New Patient Consultation and spine exam $1/2 hour

1/2/2014 99354 Additional Time of 30 minutes (total 60+ minutes) $1/2 hour

1/2/2014 X‐ray films taken today

1/2/2014 Cervical collar, cervical/thoracic traction pillow, ice pack

lumbar stabilization belt, lumbar traction support,

orthotics, natural pain relievers, natural anti‐anxiety

1/2/2014 Treatment done today

1/3/2014 99213 Existing Patient Consultations and Exams $1/4 hour

of right hand, left hand, right shoulder, left shoulder

and right elbow

1/3/2014 99354 Additional 30 minutes to complete all exams $1/2 hour


1/4/2014 99213 Existing Patient Consultations & Exams of $1/4 hour

right knee, left knee, right hip, right ankle, left foot

1/4/2014 99354 Additional 30 minutes to complete all exams


1/5/2014 Existing Patient Concussion Consult & Exam

90791 Acute Concussion Evaluation $40‐85

90791‐25 Epworth $40‐85

90791‐25 Rivermead $40‐85

90791‐25 Reactions to Stressful Car Accident (PTSD) $40‐85

96118 Folstein MMSE $75‐150


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Sample Treatment Fees First Month

98940, 1 or 2 Adjustment spine (MUST have correct number of sx, dx & examined areas)

97124 Massage (4 units x 15 minutes)

97035 Ultrasound neck (1 unit x 15 minutes)

98943 Adjustment (Extraspinal)

97532 Cognitive Training in Office (1 unit=15 minutes, may bill up to 4) $25‐55/ea

Sample Co‐Treating Specialists

Neuropsychologist and/or Psychiatrist for brain concussion

SPECT and/or PET Scan

Quantative EEG (QEEG)

LORETA neurofeedback

Psychiatrist or Endocrinologist for chemical imbalances in hormones (esp. cortisol)

Hyperbaric Oxygen Clinic for brain concussion

Neurosurgeon for (N/T “whole left side of body”)

Counselor for EMDR, hypnosis or other anxiety/PTSD treatments

Prolotherapy doctor for torn ligaments

Pain Management Doctor (after 120 days if not resolved)

NOTE: Avoid Pain Mgmt docs who only give prescriptions & don’t give treatments

Doctors I have used personally that are great:

Ripu Arora, MD (pain management) (310) 530‐3595

Christine Kraus, Ph.D. (neuropsychologist) (951) 445‐3934

Bjorn Eek, MD (Prolotherapy) (949) 215‐5533

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RE‐EXAM Proper Billing for Patient

2/4/2014 99213 Existing Patient Consultation and spine exam $1/4 hour Exams of all extremities (fill out forms) 2/4/2014 99354 Additional Time of 30 minutes (total 45+ minutes) $1/2 hour 99355 Additional Time of 60 minutes (total 75+ minutes) $1 full hour

2/4/2014 Existing Patient Concussion Consult & Exam

90791 Acute Concussion Evaluation $40‐85 90791‐51 Epworth $40‐85 90791‐51 Rivermead $40‐85 90791‐51 Reactions to Stressful Car Accident (PTSD) $40‐85 96118 Folstein MMSE $75‐150

IMPORTANT CONSIDERATIONS EACH AND EVERY RE‐EXAM

1. Did you examine ALL the joints from the LAST exam?

2. Did you make a NEW Diagnosis form?

3. Did you make a NEW Treatment Plan form?

4. Did you CHANGE your treatments to match what is actually wrong with the patient?

5. Are there ANY new specialists you need to bring in to help you THIS month?

6. Examine the patient at least EVERY 30‐35 Days!!!

7. Did you make a VIDEO of painful or graphic tests or treatments yet?

SPECIAL CONSIDERATIONS TO WATCH OUT FOR DURING EXAMS/RE‐EXAMS

1. Did you see the patient within 30 days of the accident?

If not, and you are the 1st doctor, DOCUMENT home treatments (OTC’s)

If not, did they go to the E.R., PCP, witch doctor, ANYONE?

2. Has the patient seen any OTHER doctors before you?

If yes, have you ordered AND REVIEWED the prior records with patient?

If no, how many days has it been since the accident? (>30 = cash patient)

3. Did more than 45 days go by when the patient saw NO Doctor?

If yes, you MUST explain the “Gap In Care”

4. Have you ordered the pre‐accident M.D. records AND reviewed them yet?

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Common CPT Codes and Fees New Patient E & M Codes (10) 99201 Focused Consult/Exam (10 minutes) – 1/6 of an hour (20 99202 Expanded Consult/Exam (20) – 1/3 of an hour (30) 99203 Detailed Consult/Exam (30) – 1/2 of an hour (30 minutes added to any code above) 99354 – 1/2 of an hour Existing Patient E & M Codes (5) 99211 Minimal Consult/Exam (5) – 1/12 of an hour (10) 99212 Focused Consult/Exam (10) – 1/6 of an hour (15) 99213 Expanded Consult/Exam (15) - 1/4 of an hour (30 minutes added to any code above) 99354 – 1/2 of an hour Neuropsych Screening Codes 90791 Neuropsych Consult (Rivermead, Epworth, ACE, PTSD) - $40 to $85 96118 Neuropsych Test/Interp/Rpt (Per Hr. by Doctor) - $75 to $150 Treatment Codes 98940 Chiropractic Manipulation 1 to 2 Areas-must write 1-2 sx & dx 98941 Chiropractic Manipulation 3 to 4 Areas-must write 3-4 sx & dx 98942 Chiropractic Manipulation 5 Areas-must write 5 sx areas & 5 dx areas 98943 Chiropractic Manipulation (Extremity) - $55.00 97035 Ultrasound @ 15minutes (8 or more minutes minimum) 97012 Mechanical Traction 97014 EMS Unattended 97032 EMS Attended 97110 Therapeutic Exercise 1 on 1 97124 Massage (Per 15 minutes) 97140 Myofascial Release -21 Prolonged E&M Services (usually required w/highest level E&M code continuous patient contact) -25 Significant, Separately Identifiable E&M on same day as other service -59 Distinct Procedural Service -76 Repeat Procedure by SAME doctor on the SAME day

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How to use Human Biomechanics of Trauma Institute Paperwork Day 1 1. Patient fills out Patient Information Form & brings it to the front desk 2. Patient is given Symptoms Form with the following instructions a. Blacken in the boxes like a Scantron form b. The more thorough and accurate you are, the better the doctor will be able to take care of you. c. Mark ANY symptom you have had since the accident, even if you are not having it right this minute. 3. Doctor reviews Patient Information & Symptoms Form with patient during consultation. 4. Doctor evaluates patient from Symptoms and determine which areas of the body and brain need an examination. 5. Doctor fills out Diagnosis Form & Treatment Plan Form a. 80% of the diagnosis comes from the consultation b. Treatment plan should include instructing yourself which areas to examine in detail later that week. 6. Take x-ray films if needed (send out to DACBR for read.) 7. Do any treatment that patient urgently needs. 8. Dispense any supports, braces, etc. that patient needs. 9. Doctor tells patient, “You have injured many areas of your body including (list them) and I need to examine them all. I will examine your spine tomorrow, your injured (left left shoulder, right hand and right elbow) the next day and your injured (right hip, right knee, left ankle and right foot) the day after that. (OPTIONAL) You also have a concussion and PTSD from this accident and I will need to evaluate those injuries once I have examined all your physical injuries. Does that sound reasonable to you that I am very thorough in examining you? 10. Front desk looks at Treatment Plan form and schedules follow up examinations allowing the doctor about 45-50 minutes each time for the doctor to examine various spine areas, extremity joints and brain injuries. 10. Office bills for the doctor’s TIME a. 99203 (30 minutes face to face with new patient) b. 99345 (30 additional minutes face to face with patient – total 60+ minutes) c. X-rays d. Durable medical equipment e. Treatment NOTE: Doctor’s TIME includes consultation, exam, decision making & coordination of care (ordering tests or reviewing old medical records) as long as all of is done face to face with the patient.

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Day 2 1. Patient fills out appropriate Spine Consultation forms 2. Doctor examines all injured areas for which the consultation forms were filled out. 3. Office bills for the doctor’s TIME a. 99213 (15 minutes face to face with existing patient) b. 99354 (30 additional minutes face to face with patient – total 45+ minutes) c. Treatment, x-rays, DME done on day 2 Day 3 1. Patient fills out appropriate Extremity forms (perhaps group the upper extremities?) 2. Doctor examines all injured areas for which the consultation forms were filled out. 3. Office bills for the doctor’s TIME a. 99213 (15 minutes face to face with existing patient) b. 99354 (30 additional minutes face to face with patient – total 45+ minutes) c. Treatment, x-rays, DME done on day 2 Day 4 1. Patient fills out appropriate Extremity forms (perhaps group the lower extremities?) 2. Doctor examines all injured areas for which the consultation forms were filled out. 3. Office bills for the doctor’s TIME a. 99213 (15 minutes face to face with existing patient) b. 99354 (30 additional minutes face to face with patient – total 45+ minutes) c. Treatment, x-rays, DME done on day 2 Day 5 1. Patient fills out appropriate Concussion & PTSD forms a. Rivermead Post-Concussion Questionnaire (CPT code 90791) b. Acute Concussion Evaluation (ACE) (CPT code 90791-51) c. Epworth Sleepiness Scale (CPT 90791-51) d. Assessment of Reactions to a Stressful Car Accident (CPT 90791-51) e. Doctor fills out Folstein Mini Mental State Exam with patient (CPT 96118) 2. Doctor fills out “updates” of the following forms now that all exams have been done a. Diagnosis form b. Treatment Plan form 3. Office follows the written Treatment Plan for 30 days and does a re-exam

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Re-exams (Every 30 Days) 1. Patient fills out the following forms a. Symptoms b. All appropriate spine consultation forms (where problems existed at last exam) c. All appropriate extremity forms (where problems existed at last exam) d. All appropriate brain and PTSD forms (where problems existed at last exam) e. (only at 1st re-exam and at 4 month re-exam) Duties Under Duress form f. (only at 1st re-exam and at 4 month re-exam) Loss of Enjoyment of Life form 2. Doctor does all appropriate examinations (where problems existed at last exam) 3. Office bills for Doctor’s TIME a. 99213 (15 minutes face to face) b. 99354 (30 additional minutes face to face consulting, exams, decision making) c. Bill 90701-51 for EACH of the brain or PTSD questionnaires that doctor reviewed with patient d. 96118 (up to 60 SEPARATE minutes doing Folstein MMSE) e. Follow up x-ray films taken f. Filling out Diagnosis & Treatment Plan forms (decision making) g. Filling out referrals to other doctors or ordering tests/MRI/etc. (coordination of care) h. Time spent reviewing x-ray reports, MRI reports, PCP records, ambulance records, E.R. records if done face to face with the patient (good time to explain to patient what is wrong with him/her) 120 Day Guidelines Chiropractic treatment works quickly and is very effective. If you have not returned the patient to being 100% pain free (or as good as before the accident) by 120 days, get some help. Let some other doctors have a chance to help the patient. Bring in neuropsychologist, orthopedic surgeon, neurosurgeon, Prolotherapy doctor, pain management doctor if you have not already done so. About one-third of car accident patients get 100% well from chiropractic treatment only. Two-thirds do not and that is mostly because they have torn ligaments in their spine and/or torn ligaments or tendons in their extremities. Brain concussions also tend to linger for months or years especially if the patient has the three known symptoms that are early predictors of long-term post-concussion syndrome: (1) anxiety; (2) noise sensitivity; and (3) trouble thinking. Chiropractors can predict very quickly which patients will heal in 120 days and which patients will not. Stress x-ray films showing NO torn ligaments are likely to heal within 120 days after a car accident. Patients with NO concussion symptoms, NO PTSD symptoms and NO anxiety in the first two weeks are likely to heal within 120 days. When you find torn spine or extremity ligaments OR symptoms of concussion/PTSD/Sleep you need to bring in the team of doctors immediately to help the patient.

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Collecting Your Professional Fees From All Patients (Including PI Patients) The Traditional Medical Lien is no longer a reasonable way for doctors to collect their professional fees from patients involved in personal injury cases. The modern way is to use the Medical Guarantee Lien. The Medical Guarantee Lien explicitly states that the patient is to either pay the doctor at the time services are rendered or is to make regular payments toward the balance on the account. Use the patient's health insurance and/or Medical Payments/PIP coverage to collect your professional fees where such coverage exists. If there is no insurance available, use the following scripts to collect your professional fees.

Doctor (or Assistant): Bob, you do not have any health or car insurance that will help you pay your bill at our office. Would you rather settle your account each time you come in or once a week on Friday? Patient: Once a week on Friday is fine. Doctor (or Assistant): How would you like to take car of that, cash, check, or charge? Patient: Credit card. Doctor (or Assistant): OK, then every Friday we will settle your account and zero out your balance every Friday.

(If the patient asks "How much will it cost?") Doctor (or Assistant): It will be about $500-$600 a week for the first month, $300-$400 a week for the second month, and $100-200 a week for the third month (whatever your schedule & fees dictate). Patient: OK, that will be fine. Doctor (or Assistant): How would you like to take car of that, cash, check, or charge? Patient: Check. Doctor (or Assistant): OK, then every Friday we will settle your account and zero out your balance every Friday with your check.

(If the patient says, "I can't afford that much.") Doctor (or Assistant): Bob, how often do you get paid? Patient: On the first and the fifteenth. Doctor (or Assistant): Bob, out of each paycheck you get on the first and fifteenth, how much could you afford to pay toward your balance so that your family doesn't go without food, clothing, or shelter? (do not break the silence, wait for the patient to answer.) Patient: $50 Doctor (or Assistant): OK, then we will collect $50 from you on the first and fifteenth of each month until your balance is paid off. Is that OK with you? Patient: Yes

(What if some attorney doesn't want you to collect money from the patient?) Doctor (or Assistant): Mr. Attorney, are you familiar with the legal presumption of reasonableness of the medical bills that is created when the patient has paid the bill? Attorney: Yes (he/she won't know this or they would have told you to collect in the first place.) Doctor (or Assistant): OK, then when you are trying to settle the case, you can use this legal presumption to argue when the insurance company claims my bills are not reasonable and necessary. That will help you settle the case, right? Attorney: Yes Doctor (or Assistant): OK, then. Are there any other questions today?

(What if the attorney says, "No, I'm not familiar with the presumption of reasonableness.) Doctor (or Assistant): Well, if the medical bills have been paid by either the patient or the patient's insurance company, someone has already looked at the medical bills and judged them to be reasonable before they paid them. This creates a legal presumption that they are reasonable. You don't really want me to be ambushed on the witness stand with the question, "Doctor, you're not here to tell the truth today, you'll say anything so this plaintiff wins this case so you can get paid, isn't that true, doctor?" If they ask me that, I will simply say, "I am here to tell the whole truth because I have been paid in full for my professional services and I am just here to answer your questions today."

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SCRIPT FOR SUBSTITUTING OUT AN ATTORNEY _________, I have determined that I cannot work with your attorney, not that your attorney has done anything wrong, we just have a difference of business philosophies. I hate to put you in this position today, but you are going to have to choose between your lawyer and me. If you choose me, I have several attorneys that I know and trust and that I would use if I were in a car accident myself. If you choose your attorney, there are no hard feelings on my part. Your attorney will send you to another chiropractor and that chiropractor will be the one to put their hands on you, adjust you, massage you and adjust your neck. What would you like to do? (Answer: I choose you, doc.) OK, then here are the business cards of a 3 good attorneys. The first one is the one I would use myself if I was in an accident. If you don’t like him (or her), call either of the other two because they are also excellent. And don’t worry, the new attorney will take care of talking to your old attorney for you so you don’t even have to talk to your old attorney at all. Give him/her a call this week and let me know after you have met with him/her. (Answer: I choose my attorney.) OK, there are no hard feelings of course. Thank you for letting me take care of you for this short time and if you ever have any questions, please feel free to call me personally. (stand up, shake hands) I wish you all the best. Be sure to call your attorney to get the name of another chiropractor. (Make a note in the patient’s chart that they will be calling their attorney to get a new chiropractor and that the patient self-dismissed from your care on that date.)

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California Auto Insurance

Medical Payments Coverage - This is very important to have. It pays your doctor bills if you are in an accident even if the accident was your fault. It also pays your doctor bills for you, your spouse or your children if they are riding in another car or get hit by a car riding a bike, riding a skateboard or even walking on the sidewalk or in a crosswalk. It will pay 100% for any doctor, hospital, or ambulance with no deductible up to the limits you choose. I recommend buying the highest your company sells because this coverage is very inexpensive. You can purchase $1,000, $2,000, $5,000, $10,000, $25,000 and even $100,000 from some companies. BEWARE: Some companies trick you into buying an “Excess” Medical Payments policy for a few dollars less. It is not worth it and they sometimes sneak in a $2000 deductible, too. Don’t buy “Excess” type or one with a deductible.

Uninsured/Underinsured Motorist (UM) Coverage - This is extremely important coverage for you that is also very inexpensive. What if you are hit by someone without insurance or someone who has only the minimum $15,000 policy and you spend just one day in the emergency room? Your hospital bill alone could be $50,000 or more. Your medical bills after the hospital could be $100,000 or more. UM pays not only your medical and hospital bills but also pays you for pain and suffering and reimburses you for the income you lost from missing work. Just like Medical Payments, it covers you, your spouse and your children when riding in anyone’s car or even if one of them is hit by a car when riding a bike, skateboard or walking in the crosswalk. I recommend $250,000 of UM coverage because it is very inexpensive to protect yourself and your family.

Disability - This typically pays you approximately $250 a week if you are on disability after an accident up to a maximum of $15,000. The coverage costs about $10 a year per driver (less than a dollar a month.)

Collision - This coverage pays to repair your car even if you caused the accident. The premium is based on the value of your car. There are no “minimum” or “limits” but premiums differ based on the deductible you choose. I recommend a higher deductible ($1,000 or more) because a higher deductible can save you $100 or $200 a year (so you can pay for better Medical Payments and UM.)

Comprehensive - This will pay for damage to your car by vandalism such as stealing your radio, damage by fire, wind, hail, flood, hitting an animal, or if someone steals your whole car.

Liability - This pays for the other driver’s car and injuries if you cause an accident. This coverage protects your assets if you cause an accident so buy at least $250,000.

Emergency Road Service – Pays for a tow truck and this coverage is only a few dollars a year.

Car Rental Expense - This very inexpensive coverage will pay for a rental car for you while your car is being repaired, even if the accident was your fault. It is only a few dollars a year.

Provided by: Steven C Eggleston, DC, Attorney at Law 2601 Main Street, Suite 800, Irvine, California 92614 (877) 424-4765

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AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION

Patient Name _______________________________________________________ Date of Birth _____________________ MRN# ____________________________ I authorize the following entity to release my health information:

_______________________________________ _______________________________________ _______________________________________

The information is to be released to:

Steven C Eggleston, D.C., 2601 Main Street, Suite 800

Irvine, California 92614 (877) 424-4765 / Fax (877) 883-2963

Email: [email protected] INFORMATION TO BE RELEASED BY THIS AUTHORIZATION _____ My complete medical records after _____________ _____ Diagnostic imaging films/discs after ____________ _____ Diagnostic imaging report(s) after _____________ _____ Operative, pathology, EKG and laboratory report(s) after __________ _____ Consultation, history, physical exam and E.R. records after ___________ _____ My complete medical records before _____________ _____ My billing statements for services after the date of ____________ THE PURPOSE(S) FOR DISCLOSING THIS INFORMATION IS _____ Review/Inspection of records by Dr. Eggleston _____ Continuing medical care _____ Legal purposes _____ Billing & payment of bill _____ ___________________________________________________________ I understand that the information disclosed by this authorization may be re-disclosed by the recipient and no longer protected by federal privacy regulations. I hereby give specific authorization to grant the release of mental health diagnosis or treatment. I understand that Welfare & Institutions Code 5328 requires that these mental health records must be treated as confidential. Initials _____ Date _____

Page 1 of 2 25

I understand this authorization is voluntary. I understand that treatment, payment, enrollment, or eligibility for benefits will not be conditioned on signing this authorization except if the authorization is for: (1) conducting research-related treatment; (2) obtaining information in connection with eligibility or enrollment in a health; (3) for determining an entity’s obligation to pay a claim; or (4) creating health information to provide to a third party. I understand that under no circumstances am I required to authorize the release of mental health records unless I specifically authorized the release of such records with my initials above. I understand that I may revoke this authorization at any time, provided that I do so in writing and submit it to Steven C Eggleston, DC, at the address listed above. The revocation will take effect when received by Steven C Eggleston, DC, except to the extent that Steven C Eggleston, DC or others have already relied on it. I understand that I am entitled to receive a copy of this authorization and that I may inspect the health information I am being asked to disclose. Unless otherwise revoked, this authorization expires five (5) years from the date of signing of this form. It is my intent that a photocopy, scan, email or facsimile copy of this Authorization for Release of Health Information shall be as valid as an original copy. _______________________________________ __________________ Signature of Patient Date _______________________________________ Printed Name ____________________________________________ (Legal Relationship of Signatory if not Patient)

Page 2 of 2 26

TREATMENT PLANPatient _________________________________ Today’s Date _____________ DOI _____________

______________________________The following recommended treatments are to be done through

C HBTI 2/16/2016

Cervical Spine Tx Thoracic Spine Tx

Upper Extremity Tx Lower Extremity Tx

Depression/Anxiety Plan TMJ Plan

Misc Plans

Brain Injury Plan

Lumbar Spine Tx

Pelvis/Hip/Sacrum Tx

98940(1)(2) Chiropractic Manip.9WB1XBZ Non-Manual CMT9WB1XGZ Long Lever CMT9WB1XHZ Short Lever CMT9WB1XLZ Other Type CMT97124 Massage ____ minutes97035 Ultrasound ____ minutes97014 Elect.Stim (unattended)97039 Attended FDA IR Laser97140 Myofascial Release97110 Ther.Exer. 1on1 ____min97150 Ther.Exer.Group ____minOfficeHome Exercises GymHHome Ice Pack RestMD Exam CT MRI DMX

ome Stabilization Traction

Other ________________

98940(1)(2) Chiropractic Manip.9WB2XBZ Non-Manual CMT9WB2XGZ Long Lever CMT9WB2XHZ Short Lever CMT9WB2XLZ Other Type CMT97124 Massage ____ minutes97035 Ultrasound ____ minutes97014 Elect.Stim (unattended)97039 Attended FDA IR Laser97140 Myofascial Release97110 Ther.Exer. 1on1 ____min97150 Ther.Exer.Group ____min

Home Ice Pack RestMD Exam CT MRI DMX

Office Other ________________Home Exercises GymHome Stabilization Traction



Office Other ________________Home Exercises GymHome Stabilization Traction



Home Exercises GymHome Stabilization Traction

98943 Chiropractic Manip.9WB6XBZ Non-Manual CMT9WB6XGZ Long Lever CMT9WB6XHZ Short Lever CMT9WB6XLZ Other Type CMT97124 Massage ____ minutes97035 Ultrasound ____ minutes97014 Elect.Stim (unattended)97039 Attended FDA IR Laser97140 Myofascial Release97110 Ther.Exer. 1on1 ____min97150 Ther.Exer.Group ____min



98943 Chiropractic Manip.9WB7XBZ Non-Manual CMT9WB7XGZ Long Lever CMT9WB7XHZ Short Lever CMT9WB7XLZ Other Type CMT97124 Massage ____ minutes97035 Ultrasound ____ minutes97014 Elect.Stim (unattended)97039 Attended FDA IR Laser97140 Myofascial Release97110 Ther.Exer. 1on1 ____min97150 Ther.Exer.Group ____min



90791 Cognitive Consultation96118 Cognitive Screening90791 Hypersomnolence Consultation97127 Cognitive Training In Office _____ min.97039 Attended FDA cleared IR LaserHome MeditationHome Cognitive Rehabilitation ExercisesMD ReferralNeuropsychologist ReferralCounselingPolysomnogramAvoid Stressful ActivitiesBed RestOther _______________________________

PhysiotherapyMassage TherapySplint for Home UseHome TMJ ExercisesRestricted TMJ ActivityRelaxation ExercisesSoft Food/Liquid DietDDS Referral

ExerciseMeditationAvoid Stressful ActivitiesNatural Anti-DepressantsNatural Anti-AnxietyBed RestMD ReferralCardiologist Referral

Home TENS Natural Pain RelieversCane/Crutches/Orthotics Order Impairment RatingNatural Anti-Inflammatories Re-evaluate in _____ days

____ Office Treatments per _______

____ Home Treatments per _______

Signature of Doctor ________________________________________36

Symptoms Update

Patient ____________________________________________ Date ______________ Date of Injury _____________

“Clunk” sound with neck movements

Neck pain

Upper back pain

Low back pain

Shoulder pain (left)

Shoulder pain (right)

Elbow pain (left)

Elbow pain (right)

Wrist pain (left)

Wrist pain (right)

Hand/finger pain (left)

Hand/finger pain (right)

Hip pain (left)

Hip pain (right)

Knee pain (left)

Knee pain (right)

Ankle/foot pain (left)

Ankle/foot pain (right)

Jaw/chewing pain (left)

Jaw/chewing pain (right)

Face pain

Chest/ribs pain

Stomach pain

Bruises on _____________________

Cuts/scrapes on _________________

Scars on _______________________

Numb/tingling arm/hand (left)

Numb/tingling arm/hand (right)

Numb/tingling leg/foot (left)

Numb/tingling leg/foot (right)

Weak/clumsy arm/hand (left)

Weak/clumsy arm/hand (right)

Weak/clumsy leg/foot (left)

Weak/clumsy leg/foot (right)

Stiffness in joints

Headaches

Sore or spasm in muscles

Dizzy/lightheaded/woozy

Vision changes

Sleep changes

Radiating pain

Anxiety/nervousness

Lack of enthusiasm for life

I take these medications

Patient Signature Dr. Signature

StillHave

ImprovedA Little

ImprovedMedium

ImprovedA Lot

NotImproving

GettingWorse

100%Healed

NeverHad

42

seminar notes 2017 - hbtinstitute.com

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