1 INSURANCE INFORMATION FOR MOTOR VEHICLE ACCIDENT CLAIMS Date of Accident- YYYY-MM-DD - - Your name - Name of car insurance company- Branch Location- Name of insurance adjuster- Telephone - Fax- - Name of policy holder same as above or Policy holder s name Policy number - Claim # (if known ) Are you seeing any other health practitioner for treatment as a result of this accident? (e.g. dentist, optometrist) Were you employed at the time of the accident? Y N Do you have extended health benefits? Y If YES, go to page 2. N 1
2 For motor vehicle accident claims in Ontario, the auto insurer requires the information listed below. Statutory Accident Benefits in Ontario dictate that you must use your extended health benefits towards the payment of your MVA rehabilitation. At the end of the first phase of your treatment, you will be required to pay Target Therapeutics the amount of extended health coverage that you have left for this year. We will give you a statement for you to submit to your extended health insurer for reimbursement of this amount. We will then bill the auto insurer for the remainder of our services in accordance with standardized rates. Extended Health Care Insurance Insurance Company Policy #/Plan # Name of Plan Member Member Id. Fiscal year end month (if not January) Do you have coverage for the following benefits? Chiropractic N Y max. dollar amount/year $ Physiotherapy N Y max. dollar amount/year $ Massage Therapy N Y max. dollar amount/year $ If you have unlimited physiotherapy coverage, is there a maximum dollar amount per treatment? N Y max. dollar amount/year $ Does your policy have a maximum # of visits? N Y max. number 2
3 Patient Responsibilities for Motor Vehicle Accidents Your car insurance company will be mailing you some forms to fill out. These forms are called the Accident Benefits Application Package or OCF1. It is your responsibility to fill out these forms promptly and send them back to your insurance company. Failure to do so may result in your treatments not being covered by them in which case it would be your responsibility to pay for your treatments rendered here at Target Therapeutics. If during your treatment plan here at Target Therapeutics, you see any other health professionals other than the practitioners that you are seeing here at Target Therapeutics for the treatment of your motor vehicle accident injuries, it is your responsibility to tell your treating Therapists about it because it may affect the amount of treatment that you may receive. If you settle your claim with your insurer at any point during your treatment here at Target Therapeutics you must inform us immediately in order to avoid being charged for treatments rendered by us after that point. You will be responsible to pay Target Therapeutics the amount of coverage for the extended health care that you may have for the practitioners that you see for the treatment of your injuries at our facility. Once this amount is paid, we will provide you with an invoice. It will be your responsibility to submit your claim and receive payment back from your extended health insurance company. Upon payment, the insurance company will provide you with an explanation of benefits document which will have to be given to us in order for us to process the balance of your account with the car insurance company. Name (printed) Signature Date 3
4 The following three pages of questionnaires ask about your ability to perform certain activities and how these activities affect your neck, low back and arms. Only answer the particular questionnaire if you have symptoms related to your MVA in that body area. They are designed to help us better understand how your pain allows you to manage through your activities of daily living. Please answer every question, based on how you presently feel by circling the appropriate number. If you have not performed the activity in the past week, please make your best estimate as to which response is the most accurate. Please sign and date each document in the appropriate locations. 4
5 NECK DISABILITY INDEX THIS QUESTIONNAIRE IS DESIGNED TO HELP US BETTER UNDERSTAND HOW YOUR NECK PAIN AFFECTS YOUR ABILITY TO MANAGE EVERYDAY -LIFE ACTIVITIES. PLEASE MARK IN EACH SECTION THE ONE BOX THAT APPLIES TO YOU. ALTHOUGH YOU MAY CONSIDER THAT TWO OF THE STATEMENTS IN ANY ONE SECTION RELATE TO YOU, PLEASE MARK THE BOX THAT MOST CLOSELY DESCRIBES YOUR PRESENT -DAY SITUATION. SECTION 1 - PAIN INTENSITY " I have no pain at the moment. " The pain is very mild at the moment. " The pain is moderate at the moment. " The pain is fairly severe at the moment. " The pain is very severe at the moment. " The pain is the worst imaginable at the moment. SECTION 6 CONCENTRATION " I can concentrate fully without difficulty. " I can concentrate fully with slight difficulty. " I have a fair degree of difficulty concentrating. " I have a lot of difficulty concentrating. " I have a great deal of difficulty concentrating. " I can't concentrate at all. SECTION 2 - PERSONAL CARE " I can look after myself normally without causing extra pain. " I can look after myself normally, but it causes extra pain. " It is painful to look after myself, and I am slow and careful. " I need some help but manage most of my personal care. " I need help every day in most aspects of self -care. " I do not get dressed. I wash with difficulty and stay in bed. SECTION 3 LIFTING " I can lift heavy weights without causing extra pain. " I can lift heavy weights, but it gives me extra pain. " Pain prevents me from lifting heavy weights off the floor but I can manage if items are conveniently positioned, ie. on a table. " Pain prevents me from lifting heavy weights, but I can manage light weights if they are conveniently positioned. " I can lift only very light weights. " I cannot lift or carry anything at all. SECTION 4 WORK " I can do as much work as I want. " I can only do my usual work, but no more. " I can do most of my usual work, but no more. " I can't do my usual work. " I can hardly do any work at all. " I can't do any work at all. SECTION 7 SLEEPING " I have no trouble sleeping. " My sleep is slightly disturbed for less than 1 hour. " My sleep is mildly disturbed for up to 1-2 hours. " My sleep is moderately disturbed for up to 2-3 hours. " My sleep is greatly disturbed for up to 3-5 hours. " My sleep is completely disturbed for up to 5-7 hours. SECTION 8 DRIVING " I can drive my car without neck pain. " I can drive as long as I want with slight neck pain. " I can drive as long as I want with moderate neck pain. " I can't drive as long as I want because of moderate neck pain. " I can hardly drive at all because of severe neck pain. " I can't drive my care at all because of neck pain. SECTION 9 READING " I can read as much as I want with no neck pain. " I can read as much as I want with slight neck pain. " I can read as much as I want with moderate neck pain. " I can't read as much as I want because of moderate neck pain. " I can't read as much as I want because of severe neck pain. " I can't read at all. SECTION 5 HEADACHES " I have no headaches at all. " I have slight headaches that come infrequently. " I have moderate headaches that come infrequently. " I have moderate headaches that come frequently. " I have severe headaches that come frequently. " I have headaches almost all the time. SECTION 10 RECREATION " I have no neck pain during all recreational activities. " I have some neck pain with all recreational activities. " I have some neck pain with a few recreational activities. " I have neck pain with most recreational activities. " I can hardly do recreational activities due to neck pain. " I can't do any recreational activities due to neck pain. PATIENT NAME DATE SCORE  BENCHMARK -5 = Copyright: Vernon H. and Hagino C., Vernon H, Mior S. The Neck Disability Index: A study of reliability and validity. Journal of Manipulative and Physiological Therapeutics 1991; 14: Copied with permission of the authors.
7 QuickDASH Please rate your ability to do the following activities in the last week by circling the number below the appropriate response. NO MILD MODERATE SEVERE DIFFICULTY DIFFICULTY DIFFICULTY DIFFICULTY UNABLE 1. Open a tight or new jar. 2. Do heavy household chores (e.g., wash walls, floors). 3. Carry a shopping bag or briefcase. 4. Wash your back. 5. Use a knife to cut food. 6. Recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g., golf, hammering, tennis, etc.). NOT AT ALL SLIGHTLY MODERATELY QUITE A BIT EXTREMELY 7. During the past week, to what extent has your arm, shoulder or hand problem interfered with your normal social activities with family, friends, neighbours or groups? NOT LIMITED SLIGHTLY MODERATELY VERY AT ALL LIMITED LIMITED LIMITED UNABLE 8. During the past week, were you limited in your work or other regular daily activities as a result of your arm, shoulder or hand problem? Please rate the severity of the following symptoms in the last week. (circle number) NONE MILD MODERATE SEVERE EXTREME 9. Arm, shoulder or hand pain. 10. Tingling (pins and needles) in your arm, shoulder or hand. SO MUCH NO MILD MODERATE SEVERE DIFFICULTY DIFFICULTY DIFFICULTY DIFFICULTY DIFFICULTY THAT I CAN T SLEEP 11. During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand? (circle number) QuickDASH DISABILITY/SYMPTOM SCORE = of completed responses. ( ) (sum of n responses) - 1 x 25, where n is equal to the number n A QuickDASH score may not be calculated if there is greater than 1 missing item.
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