Mva Personal Injury Intake Form Law Office - PDF by gqm11330

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									Manual Therapist                                                                                                               HEALTH INFORMATION

Patient Name !         !           !          !           !             !          !           !              !               Date ! !               !             !
Date of Injury !       !           !          !           !                 SSN# ! !           !              !               Claim# !!              !             !
A. Patient Information
Address !              !           !          !           !             !          !               City !     !           !              !               Zip !     !
Phone: Home !          !           !          !           !                 Work ! !           !              !               Cell !     !           !             !
Email Address ! !                  !          !           !             !          !           !                  Birthdate !            !           !             !
Employer !             !           !          !               Occupation !         !           !                  Work Address ! !                   !             !
Emergency Contact !                !          !           !             !          !           !                  Relationship to Patient !          !             !
Phone: Home !          !           !          !           !                 Work ! !           !              !               Cell !     !           !             !
Primary Health Care Provider
Name ! !               !           !          !           !             !              Credentials !          !           !                  Phone ! !             !
Address !              !           !          !           !             !          !               City !     !           !              !               Zip !     !
I give my massage therapist permission to consult my health care providers regarding my health and treatment.
B. Current Health Information List Health Concerns (Check all that apply)
Primary !!             !           !          !           !                        mild        moderate                disabling              constant           intermittent
                       symptoms increase w/ activity                decrease w/ activity                    getting worse              getting better            no change
Treatment received !               !          !           !             !          !           !              !           !              !           !             !
Secondary !            !           !          !           !                        mild        moderate                disabling              constant           intermittent
                       symptoms increase w/ activity                decrease w/ activity                    getting worse              getting better            no change
Treatment received !               !          !           !             !          !           !              !           !              !           !             !
Additional !           !           !          !           !                        mild        moderate                disabling              constant           intermittent
                       symptoms increase w/ activity                decrease w/ activity                    getting worse              getting better            no change
Treatment received !               !          !           !             !          !           !              !           !              !           !             !
List Daily Activities Limited by Condition
Work !     !           !           !          !           !             !          !           !              !           !              !           !             !
Home/Family !          !           !          !           !             !          !           !              !           !              !           !             !
Sleep/Self Care ! !                !          !           !             !          !           !              !           !              !           !             !
Social/Recreational !              !          !           !             !          !           !              !           !              !           !             !
List of Self-Care Routine
How do you reduce stress?!                    !           !             !          !               Pain? ! !              !              !           !             !
List ALL current medications !                !           !             !          !           !              !           !              !           !             !
C. Health History
List and Explain. Include dates and treatment received.
Allergies !            !           !          !           !             !          !           !              !           !              !           !             !
Surgeries !            !           !          !           !             !          !           !              !           !              !           !             !
InjurIes !!            !           !          !           !             !          !           !              !           !              !           !             !
Major Illnesses ! !                !          !           !             !          !           !              !           !              !           !             !
Consent for Care:          It is my choice to receive manual therapy, and I give my consent to receive treatment. I have reported all health conditions that I am
aware of and will inform my practitioner of any changes in my health.

Contract for Care:         I promise to participate as a member of my health care team. I will make sound choices regarding my treatment plan based on the
information provided by my manual therapist and other members of my health care team, and my experience of those suggestions. I agree to participate in the self
care program we select. I promise to inform my practitioner any time I feel my well-being is threatened or compromised. I expect my manual therapist to provide
safe and effective treatment.

Signature !            !           !          !           !             !          !           !                  Date ! !               !           !             !
Manual Therapist                                                              INJURY INFORMATION: AUTO ACCIDENT

Patient Name !     !         !         !           !          !          !         !            !              Date ! !          !         !
Date of Injury !   !         !         !           !              SSN# ! !         !            !              Claim# !!         !         !
1. Was there a police report?      Yes        No
2. Please describe and draw on the diagram how the accident occurred. Please indicate your car as Car-A, if you were
  decreasing or increasing or steady speed, head position, if the other car was moving, if your vehicle hit anything else after
  the initial impact, and road conditions.
  !      !         !         !         !           !          !          !         !            !          !           !         !         !
  !      !         !         !         !           !          !          !         !            !          !           !         !         !
(Please draw in this space how the accident occurred)

3. Were you aware of the approaching vehicle or did the impact catch you by surprise?                       Aware          Surprised
4. Did you lose consciousness?        Yes      No
5. Where were you seated in the vehicle? !         !          !          !         !                Were you wearing a seatbelt?         Yes      No
6. Is the top of your headrest:    Above your head           Below your head             Does your head touch the headrest?              Yes      No
7. Did any part of your body come into contact with the vehicle?             Yes        No      Explain ! !            !         !         !
  !      !         !         !         !           !          !          !         !            !          !           !         !         !
8. Is your vehicle equipped with an airbag?            Yes   No       Did it active?      Yes         No
9. Describe how you felt during and immediately after the injury: !                !            !          !           !         !         !
  !      !         !         !         !           !          !          !
  Later that same day !      !         !           !          !          !         !            !          !           !         !         !
  The next day ! !           !         !           !          !          !         !            !          !           !         !         !
  The next week !!           !         !           !          !          !         !            !          !           !         !         !
  The next month !           !         !           !          !          !         !            !          !           !         !         !
  Describe any bruises, cuts, or abrasions as a result of the injury !             !            !          !           !         !         !
10. Are your symptoms        getting better     getting worse            no change
  What makes them feel better? ! !                 !          !          !         !            !          !           !         !         !
  Worse? !         !         !         !           !          !          !         !            !          !           !         !         !
11. Which work activities are affected by the injury? ! !                !         !            !          !           !         !         !
  Have your work responsibilities changed as a result of this injury?              Yes       No Explain !              !         !         !
  What other daily activities are affected by this injury? !             !         !            !          !           !         !         !
12. Check all of the following symptoms that you have experienced since the accident:                       Loss of memory           Loss of balance
      Visual disturbances         Hearing difficulties             Difficulty breathing        Insomnia             Muscle spasm           Headaches
      Numbness         Tingling    Neck Pain           Upper back/shoulder pain           Mid-back pain           Low back pain         Other !
  !      !         !         !         !           !          !          !         !            !          !           !         !         !

Signature !        !         !         !           !          !          !         !                Date ! !           !         !         !
Provider                                                                                                                     BILLING INFORMATION

Patient Name !      !           !            !            !           !            !            !          !                Date ! !             !           !
Date of Injury !    !           !            !            !               SSN# ! !              !          !                Claim# !!            !           !

Billing Policy
Our office is set up to receive direct payment from insurance companies. For the best chance of reimbursement from your
insurance carrier, we ask that you:
  • Contact your insurance company to determine your manual therapy coverage and provider stipulations. Coverage depends on
     your insurance company and the specific plan you have chosen. We have provided a list of questions for you to ask your
     insurance representative or attorney that will help determine your eligibility for your billing service.
  • You will need a current prescription for manual therapy from a primary health care provider, such as a physician or a
     chiropractor, in order to submit your claim. Referrals are current for 90 days unless otherwise specified.

  It is important that you understand your insurance policies in order for you to budget for your manual therapy services.
You are personally responsible for all charges incurred in our office. We expect payment in full until your insurance
coverage has been verified.
  We realize that the completion of this form is an added burden to you as a consumer, and we thank you very much for
your assistance. This completed form will provide both you and our billing department with important information
regarding your manual therapy insurance benefits and enables us to process your claim in a timely fashion.

Patient Information!            !            !            !           !            Insured"s Information (if other than the patient)
Is the patient"s condition related to: ! !                !           !            Name ! !                !            !           !            !           !
   auto collision - In what state? !         !            !           !            Address !               !            !           !            !           !
   other accident !!            !            !            !           !            City !       !          !                State ! !                Zip !   !
   employment           illness !            !            !           !            Phone: Home !           !            !               Cell !   !           !
Patient status:     female          male! !               !           !            Date of Birth !         !            !           !            !           !
   single       married/partnered                other!   !           !            Sex:         female          male
Patient relationship to insured!             !            !           !            Employer"s Name or School Name !!                             !           !
   self     spouse/partner           child          other!            !            !            !          !            !           !            !           !

Insurance Information
Insurance plan name or program name !                     !           !            !            !          !            !           !            !           !
Member ID # !       !           !            !            !           !            !                Group # !           !           !            !           !
Customer service phone # !                   !            !           !                Date & Time you called ! !                   !            !           !
Name of customer service representative !                 !           !            !            !          !            !           !            !           !
Insurance claim address ! !                  !            !           !            !            !              City !   !           !                Zip !   !
Does the plan include a Physical Medicine and Rehabilitation benefit such as Massage Therapy?                                            Yes      No
Who may provide the services?             Massage Therapist                  Physical Therapist                Other
Is pre-authorization required?           Yes         No        Is a referral required?          Yes        No
Who may refer?          MD          DC       ND           PT        OD         Other !          !          !            !           !            !           !
How often does the referral need to be updated to ensure continuous coverage? !!                                        !           !            !           !
Is there a Preferred Provider list for Manual Therapists?                    Yes          No
Is Lyn Yancha / Anna Marie Mazzone / Robert Winbauer on the list?                              Yes       No

Provider                                                                                                         BILLING INFORMATION

If this is a Worker!s Compensation or Labor & Industries Claim, please fill out the following information:
Who is the attending HCP? !          !             !           !        !         !             !               Phone ! !               !        !
Date eligibility began !    !            Number of visits authorized !            !                 Number of visits remaining !                 !
Dates of coverage !         !        !             !           !         Date claim closed !                !             !             !        !

If this is a Personal Injury Claim (auto accident), please fill out the following information:
PIP policy amount !         !        !                 Dates of coverage !        !             !               PIP Available !         !        !
MedPay amount !!            !        !                 Dates of coverage !        !             !               MedPay Available !               !
Liability amount ! !        !        !                 Dates of coverage !        !             !               Liability Available !            !
Has PIP application been received?         Yes          No     Has attorney been consulted?              Yes         No         Retained?       Yes   No
Name of firm !      !        !        !             !           !        !         !             !           !             !             !        !
Address !          !        !        !             !           !        !             City !    !           !                 Zip !     !        !
Phone ! !          !        !        !             !           !         Fax !    !             !           !             !             !        !

If this is a Private Health Insurance Claim, please fill out the following information: (Or if your Personal Injury claim
defaults to secondary coverage, please fill this out)
Maximum allowable benefit for Physical Medicine/Rehabilitation/Manual Therapy !!                             !             !             !        !
In-network: Total $ !       !            # visits !!           !              Remaining $ !                 !                 # visits left !    !
Deductible $ !     !        !        !                 Satisfied to date $ !       !             !               Co-pay $ !              !        !
Out-of-network: Total $ !   !            # visits !!           !              Remaining $ !                 !                 # visits left !    !
Deductible $ !     !        !        !                 Satisfied to date $ !       !             !               Co-insurance $ ! !               !
Are these limits just for manual therapy?        Yes         No    If no, what other types of treatment do they include? !                       !
!           !      !        !        !             !           !         (i.e. physical therapy, occupational therapy, chiropractic, etc)

Assignment of Benefits: My signature below authorizes and direct payment of medical benefits for services billed to my health
care provider: Century Massage & Bodywork, Inc.

Release of Medical Records: My signature below authorizes the release of my medical records including intake forms, chart
notes, reports, and billing statements to my attorneys, health care providers, and insurance case managers, for the purpose of
processing my claims. (I will inform my practitioner immediately upon signing any exclusive Release of Medical Records with

Financial Responsibility: It is my responsibility to pay for all services provided. In the event that my insurance company
denies payment or makes a partial payment, I agree to be and remain responsible for the balance. It is also my understanding
and agreement that if Century Massage & Bodywork contracted with my insurance company at a discounted rate and the
agreed-upon fee has been satisfied, the balance owed on those specific visits will be waived.

Signature                                                                                Date

      Receipt of Notice of Privacy Practices &
          Financial and Payment Policies

I, _______________________________, have received a
copy of Century Massage & Bodywork, Inc. (CMB)’s
Notice of Privacy Practices and Financial and Payment

I understand that CMB is committed to serving their
customers with professionalism and caring, being sure that
at all times to protect my privacy and surety of all of my
Protected Health Information.

Client’s Signature ________________________________
Date ___________________________________________


Century Massage & Bodywork, Inc. (CMB) understands that your medical information is private and
confidential. Further, we are required by law to maintain the privacy of “protected health
information” (PHI). PHI includes any individually identifiable information that we obtain from you or
others that relates to your past, present or future physical or mental health, the health care you have
received, or payment for your health care.

As required by law, this notice provides you with information about your rights and our legal duties and
privacy practices with respect to the privacy of PHI. This notice also discusses the uses and disclosures we
will make of your PHI. We must comply with the provisions of this notice as currently in effect, although
we reserve the right to change the terms of this notice from time to time and to make the revised notice
effective for all PHI we maintain. You can always request a written copy of our most current privacy
notice from the CMB’s Privacy Officer.

                                PERMITTED USES AND DISCLOSURES

We can use or disclose your PHI for purposes of treatment, payment and health care operations. For each
of these categories of uses and disclosures, we have provided a description and an example below.
However, not every particular use or disclosure in every category will be listed.
 • Treatment means the provision, coordination or management of your health care, including
consultations between health care providers regarding your care and referrals for health care from one health
care provider to another. For example, a doctor treating you for a broken leg may need to know if you
have diabetes because diabetes may slow the healing process. In addition, the doctor may need to contact a
physical therapist to create the exercise regimen appropriate to your care.
• Payment means the activities we undertake to obtain reimbursement for the health care provided to
you, including billing, collections, claims management, determinations of eligibility and coverage and
utilization review activities. For example, prior to providing health care services, we may need to provide
information to your Third Party Payor about your medical condition to determine whether the proposed
course of treatment will be covered. When we subsequently bill the Third Party Payor for the services
rendered to you, we can provide the Third Party Payor with information regarding your care if necessary to
obtain payment. Federal or State law may require us to obtain a written release from you prior to
disclosing certain specially PHI for payment purposes, and we will ask you to sign a release when
necessary under applicable law.
• Health care operations means the support functions of our practice related to treatment and payment,
such as quality assurance activities, case management, receiving and responding to patient comments and
complaints, physician reviews, compliance programs, audits, business planning, development,
management and administrative activities. For example, we may use your PHI to evaluate the performance
of our staff when caring for you. We may also combine PHI about many patients to decide what additional
services we should offer, what services are not needed, and whether certain new treatments are effective. In
addition, we may remove information that identifies you from your patient information so that others can
use the de-identified information to study health care and health care delivery without learning who you


In addition to using and disclosing your information for treatment, payment and health care operations, we
may use your PHI in the following ways:

•     We may contact you to provide appointment reminders for treatment or medical care.
 •    We may contact you to tell you about or recommend possible treatment alternatives or other health-
related benefits and services that may be of interest to you.
 • We may disclose to your family or friends or any other individual identified by you PHI directly
relevant to such person’s involvement with your care or payment for your care. We may use or disclose
your PHI to notify, or assist in the notification of, a family member, a personal representative, or another
person responsible for your care of your location, general condition or death. If you are present or
otherwise available, we will give you an opportunity to object to these disclosures, and we will not make
these disclosures if you object. If you are not present or otherwise available, we will determine whether a
disclosure to your family or friends is in your best interest, taking into account the circumstances and
based upon our professional judgment.
 • When permitted by law, we may coordinate our uses and disclosures of PHI with public or private
entities authorized by law or by charter to assist in disaster relief efforts.
• We may contact you as part of our efforts to market our practice’s services as permitted by applicable
• Subject to applicable law, we may make incidental uses and disclosures of PHI. Incidental uses and
disclosures are by-products of otherwise permitted uses or disclosures which are limited in nature and
cannot be reasonably prevented.
 • We will use or disclose PHI about you when required to do so by applicable law.

[Note: In accordance with applicable law, we may disclose your PHI to your employer if we are retained
 to conduct an evaluation relating to medical surveillance of your workplace or to evaluate whether you
 have a work-related illness or injury. Your employer or CMB will notify you of these disclosures as
 required by applicable law.]

                                          SPECIAL SITUATIONS

Subject to the requirements of applicable law, we will make the following uses and disclosures of your
 • Military and Veterans. If you are a member of the Armed Forces, we may release PHI about you as
required by military command authorities. We may also release PHI about foreign military personnel to
the appropriate foreign military authority.
• Worker’s Compensation. We may release PHI about you for programs that provide benefits for work-
related injuries or illnesses.
 • Public Health Activities. We may disclose PHI about you for public health activities, including
disclosures to prevent or control disease, injury or disability; to report child abuse or neglect; to notify a
person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or
condition; to notify the appropriate government authority if we believe that an adult patient has been the
victim of abuse, neglect or domestic violence. We will only make this disclosure if the patient agrees or
when required or authorized by law.
 • Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose PHI about you
in response to a court or administrative order. We may also disclose PHI about you in response to a
subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if
CMB is given assurances that efforts have been made by the person making the request to tell you about
the request or to obtain an order protecting the information requested.
 • Law Enforcement. We may release PHI if asked to do so by law enforcement officials.
 • Serious Threats. As permitted by applicable law and standards of ethical conduct, we may use and
disclose PHI if we, in good faith, believe that the use or disclosure is necessary to prevent or lessen a
serious and imminent threat to the health or safety of a person or the public or is necessary for law
enforcement authorities to identify or apprehend an individual.

Note: HIV-related information, genetic information, alcohol and/or substance abuse records, mental health
records and other special PHI may enjoy certain special confidentiality protections under applicable State
and Federal law. Any disclosures of these types of records will be subject to these special protections.

                                       OTHER USES OF YOUR PHI

Other uses and disclosures of PHI not covered by this notice or the laws that apply to us will be made only
with your permission in a written authorization. You have the right to revoke that authorization at any
time, provided that the revocation is in writing, except to the extent that we already have taken action in
reliance on your authorization.

                                              YOUR RIGHTS

1. You have the right to request restrictions on our uses and disclosures of PHI for treatment, payment
and health care operations. However, we are not required to agree to your request. To request a restriction,
you must make your request in writing to the CMB’s Privacy Officer.
 2. You have the right to reasonably request to receive confidential communications of PHI by alternative
means or at alternative locations. To make such a request, you must submit your request in writing to the
CMB’s Privacy Officer.
 3. You have the right to inspect and copy the PHI contained in your medical and billing records and in
any other Practice records used by us to make decisions about you. In order to inspect and copy your PHI,
you must submit your request in writing to the CMB’s Privacy Officer. If you request a copy of your
PHI, we may charge you a fee for the costs of copying and mailing your records, as well as other costs
associated with your request. If we deny a request for access for any of the three reasons described above,
then you have the right to have our denial reviewed in accordance with the requirements of applicable law.
 4. You have the right to request an amendment to your PHI, but we may deny your request for
amendment. In order to request an amendment to your PHI, you must submit your request in writing to
the CMB’s Privacy Officer, along with a description of the reason for your request.
 5. You have the right to receive an accounting of disclosures of PHI made by us to individuals or entities
other than to you for the six years prior to your request. To request an accounting of disclosures of your
PHI, you must submit your request in writing to the CMB’s Privacy Officer. Your request must state a
specific time period for the accounting. The first accounting you request within a twelve (12) month
period will be free. For additional accountings, we may charge you for the costs of providing the list. We
will notify you of the costs involved, and you may choose to withdraw or modify your request at that time
before any costs are incurred.


If you believe that your privacy rights have been violated, you should immediately contact the CMB’s
Privacy Officer. We will not take action against you for filing a complaint. You also may file a complaint
with the Secretary of Health and Human Services.

                                           CONTACT PERSON

If you have any questions or would like further information about this notice, please contact the CMB’s
Privacy Officer at 15 South Grady Way, Suite LL-19, Renton, WA 98057, 425-228-5217.

                        This notice is effective as of May 7, 2003.
                                     Revised October 29, 2009
 Century Massage & Bodywork's Policies:

Financial Policy

Century Massage & Bodywork, Inc (CM&B) is implementing its Financial and
Payment Policies in order to be clear and consistent in its dealings in the
financial matters of the business. CM&B's source of income for operating
expenses is the payments received from its patients and insurance payors for
services received. In order to meet our goal, the clinic(s) must remain in a sound
financial position. We don't render services to collect money - but we must
collect money to render services.
We need the support of our clients and patients. By promptly meeting your
obligations, we are better able to continue providing quality health care to the
families of Western Washington.

Payment Policy
Payment is expected to be paid in full at the day of service at a discounted
rate (See “Price List”). We are happy to accept cash, your check or a credit
card (Visa or MasterCard) for payment of your session. There is a $35 charge
for returned check fees.

We accept Personal Injury, Workman's Compensation, and L&I claims.

We honor medical health insurance, especially within the First Choice Health
Network (FCHN), after verification. We will accept any other medical insurance
on a case-by-case basis.

You must bring your current health insurance card with you each time you
come to the office. This is very important. You may not appreciate the subtle
changes your employer has made in your benefit plan that will be reflected on
your insurance card. Bringing your card with you each visit is important for you
and for us.

If your insurance plan requires you to pay a "copay" for your visit with us,
you must make that payment at the time of your visit. We are happy to
accept cash, your check or a credit card (Visa , MasterCard, American Express,
or Discover) for payment of your copay. There is a $35 charge for returned
check fees. Be aware that most plans require a copay for each member of the
family, so if you bring another member of the family with you, two or more
"copay" amounts will be due.

Payment of the amount you owe is due within 30 days of the date of the
statement or a monthly interest of 1% will be applied. If payment of your
portion of the bill for which you are responsible is not made after the second
statement has been sent, our office will contact you to arrange payment. We
automatically send all overdue accounts promptly to our collection agency
and the credit bureau is notified.

CM&B will limit its acceptance of third party insurance claims. This is usually an
auto accident with the legal representation in which the case awaits settlement.
CM&B will require a minimum payment of $45 of the day's service(s) until an
unpaid balance of $1,500 is reached. The client will be responsible for 100%
of any amount after $1,500 based on current Time of Service prices (See
“Price List”).

Any unpaid balances between $400 and $1,000 (other than 3rd party claims)
must be paid in full within four (4) month.

Other Policy Considerations

The previous policy specifies the desired payment arrangements. From time to
time, exceptions will need to be made based on the patient's circumstances. It is
our intention and goal to be respectful of the patient's financial condition.

Cancellation Policy

Our time together is important. We recommend that you schedule your
appointment(s) in advance. We require 24-hour advance notice for
cancellations or reschedules, or you will be charged for the full amount of your
scheduled session. This also applies to gift certificates and pre-paid massage
packages. If you must cancel or reschedule your appointment, please provide at
least a 24-hour advance notice to avoid charges.

Tardiness Policy

We request that you arrive early for your appointment. This gives you some time
to relax and ensures that you will receive your full session time, and in order for
us to uphold our professional standards of being ‘on time,’ we regret that we
cannot give you additional time if you arrive late for your appointment. If for any
reason WE are late starting your appointment, you will receive the full
scheduled time.

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