New Patient Forms

NewPatientPacketNew Patient Packet
Contains Patient Registration, Current Condition Form, Patient History Form, HIPAA, Financial Policy, and Terms of Acceptance. Open in Adobe Reader or Acrobat for fill-able form fields.
Assignment_ReleaseInsurance Assignment & Release
This form is for when you want us to bill insurance or a party other than yourself.
Release of Records and Films to Valente Chiropractic
Complete this form if you have records and/or X-Ray films at another office that you’d like sent to us.

Injured in an Accident?

Motor Vehicle Collision
Work_Injury_FormWork Injury Form
Opening an LNI Claim?
You can start your claim by filling out a Report of Accident ahead of time online here:
http://www.lni.wa.gov/ORLI/ECS/default.asp?Pub=Worker
Don’t worry, you can also fill it out on paper in our office, if that is your preference. If you open a claim online – don’t forget to let us know!

Existing Patient Forms

Current Condition Form Condtion Update Form aka Pain Form
The Condition Update Form helps us keep track of how your condition is progressing from your point of view. We’ll ask you to fill out an update form once a month or whenever there is a significant change in your condition.

HIPAA HIPAA Notice of Privacy Practices
Notifies you of your privacy rights and how your information may be used in our office. This form also allows you to specify if there is a trusted family member that we may share information with and of what kind. Filled out once a year.
Assignment_ReleaseInsurance Assignment and Release
This form is for when you want us to bill insurance or a party other than yourself. Filled out once a year or when your insurance changes.
Auth to Release RecordsAuthorization to Release Records
Complete this form when you’d like us to release your medical records and/or X-Ray films to an outside party.