Get documents about "New Auto Accident Patient Intake
Document Sample
Referred By:_______________________
PATIENT INFORMATION
(auto accident)
Name________________________________________Todayʼs Date_______________________
Date of Birth_________________ Height___________ Weight___________ Dominant Hand? R L
Address _________________________________ City________________________ Zip ____________
Phone (cell) ________________________________Phone (other) ______________________________
Email ____________________________________ DL#_______________________________________
Health Insurance Company _________________________ Policy# ______________________________
Address _________________________________ City _______________________ Zip _____________
Adjuster _________________________________ Phone _____________________________________
Car Insurance Company ________________________________________________________________
Address _________________________________ City _______________________ Zip _____________
Adjuster _________________________________ Phone _____________________________________
Agent ___________________________________ Phone _____________________________________
Policy # _________________________________ Claim # _____________________________________
What Medical Payment Coverage? ____________ What Uninsured Motorist Coverage? _____________
What Law Firm Represents You? _________________________________________________________
Address _________________________________ City _______________________ Zip _____________
Name of your Personal M.D. _________________________ Phone _____________________________
Address _________________________________ City _______________________ Zip _____________
Write any Ambulance, Hospital, M.D., Chiropractor, Dentist, Acupuncturist, PT, etc., since accident
Name" " " Type Phone Amount of Bill Records Received
(For Office Use)
_______________________ ______ ___________________ _____________ ____________
_______________________ ______ ___________________ _____________ ____________
_______________________ ______ ___________________ _____________ ____________
_______________________ ______ ___________________ _____________ ____________
Please explain in detail how your accident happened. Use the back of form if you need more room:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Symptoms
Patient ___________________________ Date ____________ Date of Injury ___________
Initial Update
Please fill in all symptoms you currently have that you did not have before the accident.
Orthopedic & Musculoskeletal Symptoms
“Clunk” Sound with Neck Movements Social Withdrawl/Feeling isolated
Neck Pain Sleepiness
Upper Back Pain Nausea
Low Back Pain Vomiting
Shoulder Pain Left Right Seizure
Upper Arm Pain Left Right Difficulty Concentrating
Elbow Pain Left Right Day Dreaming
Forearm Pain Left Right Mindless Staring
Wrist Pain Left Right Mood Swings
Hand Pain Left Right Agitation
Hip Pain Left Right Sadness
Upper Leg Pain Left Right Blurry Vision
Knee Pain Left Right Double Vision
Lower Leg Pain Left Right Disoriented
Ankle Pain Left Right Confused
Foot Pain Left Right Difficulty Speaking
Jaw Pain Headache
Clicking in Jaw Attention Problems
Pain when Chewing Appetite Change
Face Pain Pupils Different Sizes
Chest Pain Dizziness
Stomach Pain Balance Problems
Bruise to _______________________ Difficulty Walking
Scrape/Cut to ___________________ Groggy
Other Symptom _________________ Very Tired
Other Symptom _________________ Dozing During The Day
Neurological Symptoms Personality Change
Numbness in Arms or Hands Can’t Remember Numbers
Numbness in Legs or Feet Reading Problems
Tingling in Arms or Hands Writing Problems
Tingling in Legs or Feet Difficulty with Adding/Subtracting
Weakness in Arms or Hands Poor Attention
Weakness in Legs or Feet Difficulty Learning New Things
Difficulty Understanding
Brain/Neuropsych/MTBI Symptoms Difficulty Remembering
Flashbacks to Accident Re-reading Things to Understand It
Impatience Anger
Frustration Difficulty Making Decisions
Wanting to be Alone Slurred Speech
Hearing Problems Depression
Change in Sense of Taste Change in Sexual Functioning
Change in Sense of Smell Anxiety/Nervousness
Sleeping Problems Reduced Confidence
Difficulty with Hand Coordination Helplessness
Difficulty Planning or Organizing Apathy (Don’t Care)
I am more easily Distracted Irritable
C HBTInstitute.com
REVIEW OF SYSTEMS
-Please check all the apply-
GASTRO-INTESTINAL! SKIN PLEASE CIRCLE ANY AREAS
___Jaundice!! ! ! ___Hives of allergy WHERE YOU FEEL PAIN BELOW
___Bladder trouble! ! ! ___Sensitive skin
___Poor appetite! ! ! ___Boils
___Poor Digestion! ! ! ___Dryness
___Excessive Ulcer!! ! ___Bruising !
___Belching/Gas! ! ! ___Itching
___Nausea! ! ! ! ___Skin eruptions
___Vomiting
___Vomiting Blood! ! ! RESPIRATORY
___Stomach Discomfort! ! ___Chronic cough
___Constipation! ! ! ___Spitting phlegm
___Diarrhea ! ! ! ___Chest pain
___Colon Trouble ___Difficulty breathing
___Hemorrhoids ___Lung problems
___Liver Trouble
GENITO-URINARY
CARDIOVASCULAR ___Frequent urination
___Strokes! ! ! ! ___Painful urination
___Poor circulation ___Blood in urine
___Heart problems ___Kidney infection
___High blood pressure ___Bladder infection
___Swelling of ankles ___Bed wetting
! ! ! ! ! ___Inability to control urinating
EAR, EYE, NOSE, THROAT ___Prostate trouble
___Ear problems! ! ! ! ! !
___Thyroid trouble! ! ! WOMEN ONLY
___Poor vision! ! ! ___Irregular periods
___Pain in eyes! ! ! ___Hot flashes
___Deafness!! ! ! ___Cramps/Backaches
___Sinus trouble! ! ! ___Miscarriage
___Tonsillitis!! ! ! ___Vaginal discharge
___Frequent colds! ! ! ___Pregnant now
___Asthma
___Hay fever
___Hoarseness
___Nose bleeds
___Sore throat
1500 W. Gore Street Orlando, FL 32805 PH: (407) 425-6578 Fax: (407)872-1165
781 Maitland Ave Altamonte Springs, FL 32701 PH: (407) 339-2888 Fax: (407) 831-3085
www.FulmoreChiropractic.com
Duties Under Duress Index
Have you continued to do any of the following activities despite the pain caused by your collision?
q Work
Why have you continued to work?
q I would lose my job if I took time off.
q I couldn’t support my family otherwise.
q I don’t believe in taking time off even when I am injured or in pain.
q My business would fail if I did not work.
q I cannot take time off, because I care for my own children.
q Other: ____________________________________________________________
q I have experienced the following changes in my ability to perform at work:
a. q Mobility / Stability Problems
i. q Climbing
ii. q Kneeling
iii. q Lifting
iv. q Walking for Long Periods
b. q Dexterity Problems
i. q Finger Movements
ii. q Wrist Movements
c. q Problems with Fatigue
d. q Postural Difficulties
i. q Bending
ii. q Sitting for Long Periods
iii. q Standing for Long Periods
iv. q Stooping
e. q Problems with Anxiety / Depression
f. q Problems with Vertigo or Spinning Sensations
i. q Dizziness
ii. q Giddiness
iii. q Sensation of Irregular Motion
iv. q Sensation of Whirling Motion
g. q Problems with Tinnitus or Ringing in the Ears
h. q Problems with Reduced Concentration
i. q Can’t Concentrate
ii. q Can’t Think Properly
iii. q Making Mistakes
i. q Pain
i. Where?_______________________________________________________
q Duration of Symptoms
a. q I experienced problems doing my normal work activities for _____ weeks.
b. q My doctors have instructed me that my inability to perform my normal pre-accident
work activities without pain is a permanent condition.
c. q My problems in performing my normal work activities is ongoing, but my doctors
have not instructed me that the conditions is permanent.
q Domestic Duties
q I have experienced pain while performing the following activities inside my home, but have
done them anyway:
a. q Laundry
b. q Dishwashing
c. q Vacuuming
d. q Washing Windows
e. q Cleaning
f. q Preparing Meals
q Due to my injuries, I have brought in the following assistance:
a. q Paid Housekeeper
b. q Unpaid Assistance
c. q None
q My family status would best be described as:
a. q Single
b. q Single Parent at Home
c. q Spouse Only
d. q Spouse and Children at Home
q I have the following number of children:
a. q 0
b. q 1
c. q 2
d. q 3
e. q 4
f. q 5
g. q ____
q The number of my children in the following age category is:
a. q Number of children 0 to 5 years: __________
b. q Number of children 5-11 years: ___________
c. q Number of children older than 11:_________
q Domestic Assistance
a. q I do receive domestic assistance
b. q I do not receive domestic assistance
q Duration of Symptoms
a. q I experienced problems doing my normal domestic activities for _____ weeks.
b. q My doctors have instructed me that my inability to perform my normal pre-accident
domestic activities without pain is a permanent condition.
c. q My problems in performing my normal domestic activities is ongoing, but my
doctors have not instructed me that the conditions is permanent.
q Household
q I have experienced problems with the following activities outside my home:
a. q Painting the Outside of the House
b. q Landscaping
c. q Mowing the Grass
d. q Trimming the Bushes / Trees
e. q Washing Windows
f. q Gardening
g. q Taking Out the Trash
h. q Washing the Cars
i. q Maintaining the Cars
j. q Maintaining Yard Equipment
k. q Doing Other External House Work; Specify: _____________________________
q Duration of Symptoms
a. q I experienced problems doing my normal household activities for _____ weeks.
b. q My doctors have instructed me that my inability to perform my normal pre-accident
household activities without pain is a permanent condition.
c. q My problems in performing my normal household activities is ongoing, but my
doctors have not instructed me that the conditions is permanent.
q Studies / Educational Duties
q As a student I have experienced problems with one of the following activities since the
collision:
a. q Carrying Books
b. q Sitting in Classes
c. q Looking Down to Read Textbooks
d. q Other: ____________________________________________________________
q I have also experienced the following changes in my ability to perform at school as a result
of injuries sustained in this collision:
a. q Mobility / Stability Problems
i. q Climbing
ii. q Kneeling
iii. q Lifting
iv. q Walking for Long Periods
b. q Dexterity Problems
i. q Finger Movements
ii. q Wrist Movements
c. q Problems with Fatigue
d. q Postural Difficulties
i. Bending
ii. Sitting for Long Periods
iii. Standing for Long Periods
iv. Stooping
e. q Problems with Anxiety / Depression
f. q Problems with Vertigo or Spinning Sensations
i. Dizziness
ii. Giddiness
iii. Sensation of Irregular Motion
iv. Sensation of Whirling Motion
g. q Problems with Tinnitus or Ringing in the Ears
h. q Problems with Reduced Concentration
i. Can’t Concentrate
ii. Can’t Think Properly
iii. Making Mistakes
i. q Pain: Where?_______________________________________________________
At the time of this collision, my education would best be described as:
a. q High School
b. q Apprenticeship Studies
c. q Technical College
d. q University
e. q Correspondence Course
My attendance before the collision is best described as:
a. q Full Time
b. q Part Time
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1500 W. Gore Street Orlando, FL 32805 PH: (407) 425-6578 Fax: (407)872-1165
781 Maitland Ave Altamonte Springs, FL 32701 PH: (407) 339-2888 Fax: (407) 831-3085
www.FulmoreChiropractic.com
NOTICE OF PRIVACY PRACTICES
-PATIENT ACKNOWLEDGEMENT-
Patient Name: ___________________________ Date of Birth: ___________________
I have received and understand this practiceʼs NOTICE OF PRIVACY PRACTICES
written in plain language. This notice provides in detail the uses and disclosures of my
protected health information that may be made by the practice, my individual rights, how
I may exercise the rights, and the practiceʼs legal duties with respect to my information.
I understand that this practice reserves the right to change the terms of its NOTICE OF
PRIVACY PRACTICES, and to make changes regarding all protected health information
resident at, or controlled by, this practice. If changes to the policy occur, this practice will
provide me a revised NOTICE OF PRIVACY PRACTICES, upon request.
_______________________________ _____________________ ______________
Patient/Guardian Signature" " Relationship to patient Date
" " " " " " " if a minor
1500 W. Gore Street Orlando, FL 32805 PH: (407) 425-6578 Fax: (407)872-1165
781 Maitland Ave Altamonte Springs, FL 32701 PH: (407) 339-2888 Fax: (407) 831-3085
www.FulmoreChiropractic.com
ASSIGNMENT OF BENEFITS FORM
The undersigned patient hereby assigns the benefits of insurance under the policy of
automobile insurance with _______________________ to Ronald L. Fulmore, D.C. for
name of insurance company
services rendered to the undersigned patient and covered by the Personal Injury
Protection (PIP) coverage under _______________________ʼs policy with
name of insured
_______________________ and in accordance with Florida Statute 627.736(5). The
name of insurance company
undersigned further agrees to pay any applicable deductible or co-payment not covered
by the PIP insurance coverage.
________________________________
Patient Signature
________________________________
Date
The undersigned hereby accepts assignment of benefits for services to
_______________________ and to be paid directly to our facility under
name of patient
_______________________ʼs Personal Injury Protection (PIP) with
name of insured
_______________________ and in accordance with Florida Statute 627.736(5).
name of insurance company
________________________________
Medical Providerʼs Signature
________________________________
Date
1500 W. Gore Street Orlando, FL 32805 PH: (407) 425-6578 Fax: (407)872-1165
781 Maitland Ave Altamonte Springs, FL 32701 PH: (407) 339-2888 Fax: (407) 831-3085
www.FulmoreChiropractic.com
AUTHORIZATION FOR DIRECT PAYMENT OF INSURANCE BENEFITS
TO MEDICAL PROVIDER
I hereby authorize and direct ________________________________ to release any and all information
regarding my insurance policy, including benefit information, PIP payout logs, and any other applicable
information and to pay by check made payable to and mailed directly to Fulmore & Associates
Chiropractic and Spinal Injury Centers, P.A. for medical and professional expenses allowable and
otherwise payable to me under my current insurance policy as payment toward the total charges for
professional services rendered by the above name medical provider. This payment will exceed my
indebtedness to the above named medical service provider. I understand that I remain personally liable
for, and agree to pay in a timely manner, any balance of said professional service charges over and
above this insurance payment. I further understand that such payment is not contingent upon any
settlement claim, or verdict by which I may recover said fee. If my current policy prohibits direct payment
to my medical provider, then I hereby instruct and direct you to make the check payable to me and my
medical provider and mail it to the following address:
781 Maitland Avenue
Altamonte Springs, FL 32701
Furthermore, I authorize the above mentioned office to and hereby give power of attorney to said office to
endorse/sign my name on any and all checks for payment of medical services provided by said office and
grant a lien to said medical services provided for any proceeds or insurance benefits payable under my
policy. A photocopy of this instrument shall be considered as effective and valid as the original. I also
authorize the release of any information pertinent to my case to the insurance company and its adjuster to
the extent necessary to obtain payment for medical services.
All previous assignments, authorizations, and records release agreements entered into between the
parties are hereby rescinded, repealed, and otherwise null and void as if never entered into, effective
immediately. This instrument is not intended to operate as an assignment as that term used in Florida
Statue 627.756 and provision(s) of this instrument that may be interpreted as such shall be considered
null and void from the beginning and the remaining provision(s) of this instrument shall be served from
said provision(s) and willl remain in full force, effect, and operation.
Executed this ________ day of ________________, 20____.
____________________________! ! ____________________________
Claimant Name! ! ! ! ! Claimant signature
____________________________! ! ____________________________
! Medical Provider! ! ! ! ! Witness
Cc: Attorney _____________________________________
!
! Insurance Company _____________________________________
1500 W. Gore Street Orlando, FL 32805 PH: (407) 425-6578 Fax: (407)872-1165
781 Maitland Ave Altamonte Springs, FL 32701 PH: (407) 339-2888 Fax: (407) 831-3085
www.FulmoreChiropractic.com
PATIENT LIEN AGREEMENT
ATTORNEY ______________! ! ! RE: ________________________
________________________ DOI: _______________________
________________________
I do hereby authorize Fulmore & Associates Chiropractic and Spinal Injury Centers, P.A.
to furnish to you, my attorney, with a full report of his examination, diagnosis, treatment
plan, prognosis, etc. of myself with regards to the accident in which I was involved.
I hereby authorize and direct my attorney to pay directly to Fulmore & Associates
Chiropractic and Spinal Injury Centers, P.A. such sums as may be due and owing him
for medical services rendered to both by reason of this accident and by reason of any
other settlement, judgement, or verdict as may be necessary to adequately protect
Fulmore & Associates Chiropractic and Spinal Injury Centers, P.A.
I fully understand that I am directly and fully responsible to Fulmore & Associates
Chiropractic and Spinal Injury Centers, P.A. for all medical bills for services rendered to
me. This agreement is made solely for Fulmore & Associates Chiropractic and Spinal
Injury Centers, P.A. additional protection and consideration of his awaiting payment. I
further understand that such payment is not contingent of any settlement, judgement, or
verdict by which I may eventually recover said fee.
__________________________ _________________________ ___________
Patient/Guardian Signature Relationship to Patient Date
Attorney please sign and date and return to our office as soon as possible. If there are
any questions, please contact our office.
__________________________ ___________
Attorney Signature Date
1500 W. Gore Street Orlando, FL 32805 PH: (407) 425-6578 Fax: (407)872-1165
781 Maitland Ave Altamonte Springs, FL 32701 PH: (407) 339-2888 Fax: (407) 831-3085
www.FulmoreChiropractic.com
OFFICE OF INSURANCE REGULATION
Bureau of Property & Casualty Forms and Rates
Standard Disclosure and Acknowledgement Form
Personal Injury Protection - Initial Treatment or Service Provided
The undersigned insured person (or guardian of such person) affirms:
1. The services or treatment set forth below were actually rendered. This means that those services have already been
provided.
2. I have the right and the duty to confirm that the services have already been provided.
3. I was not solicited by any person to seek any services from the medical provider of the services described above.
4. The medical provider has explained the services to me for which payment is being claimed.
5. If I notify the insurer in writing of a billing error, I may be entitled to a portion of any reduction in the amounts paid
by my motor vehicle insurer. If entitled, my share would be at least 20% of the amount of the reduction, up to $500.
Insured Person (patient receiving treatment or services) or Guardian of Insured Person:
Name (PRINT or TYPE) Signature Date
The undersigned licensed medical professional or medical director, if applicable, affirms the statement numbered 1 above
and also:
A. I have not solicited or caused the insured person, who was involved in a motor vehicle accident, to be solicited to
make a claim for Personal Injury Protection benefits.
B. The treatment or services rendered were explained to the insured person, or his or her guardian, sufficiently for that
person to sign this form with informed consent.
C. The accompanying statement or bill is properly completed in all material provisions and all relevant information has
been provided therein. This means that each request for information has been responded to truthfully, accurately, and in
a substantially complete manner.
D. The coding of procedures on the accompanying statement or bill is proper. This means that no service has been
upcoded, unbundled, or constitutes an invalid or not medically necessary diagnostic test as defined by Section
627.732(14) and (15), Florida Statutes or Section 627.736(5)(b)6, Florida Statutes.
Licensed Medical Professional Rendering Treatment/Services or Medical Director, if applicable (Signature by his/ her own
hand):
Name (PRINT or TYPE) Signature Date
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of Claim or an
application containing any false, incomplete, or misleading information is guilty of a felony of the third degree per Section
817.234(1)(b), Florida Statutes.
Note: The original of this form must be furnished to the insurer pursuant to Section 627.736(4)(b), Florida Statutes and may
not be electronically furnished. Failure to furnish this form may result in non-payment of the claim.
OIR-B1-1571
Pub. 1/2004
