FLORIDA CHIROPRACTIC CLINICS PIP New Patient Information Packet

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1 FLORIDA CHIROPRACTIC CLINICS PIP New Patient Information Packet Date of Entry into this office: Date of Injury: NAME: D.O.B. SS#: Sex: [ ] Male [ ] Female Status: [ ] Married [ ] Single [ ] Widowed [ ] Divorced Address: City: St.: Zip: Home Ph. #: Work Ph. #: Employed by: Medical Doctor: Phone #: Date of Last Visit: Have you consulted anyone else for this condition? [ ] Yes [ ] No If Yes, Whom did you consult and when? If Yes, What treatment was given? *** Please list any allergies: *** Please list any medications you are taking at this time: IN THE CASE OF AN EMERGENCY, WHO MAY WE CONTACT: Name: Phone #:

2 Insurance Company: Phone #: Address: City: St.: Zip: Was this accident reported to your insurance company? [ ] Yes ( IF NO, please do this TODAY) [ ] No Claim #: Policy #: Adjuster: Phone #: Ext: Insured: [ ] Self [ ] Spouse [ ] Child [ ] Other Insured Name: If Insured is other than SELF, please complete: Insured Address: Phone #: D.O.B.: SS#: Second Insurance Company: Ph.#: Address: City: St.: Zip: Claim #: Policy #: Insured Name: Have you signed with an attorney? [ ] Yes [ ] No If Yes, Whom: Address: City: St.: Zip: Phone #: Fax #:

3 FLORIDA CHIROPRACTIC CLINICS Automobile Accident Questionnaire Please Answer ALL Questions Completely What was the DATE and Time of the accident? Which Direction were you heading? [ ] North [ ] South [ ] East [ ] West On what street or intersection? Which direction was the other person(s) headed?[ ] North [ ] South [ ] East [ ]West On what street or intersection? Were the police notified? [ ] Yes [ ] No Who was cited? Were you knocked unconscious? [ ] Yes [ ] No Were you struck from: [ ] behind [ ] front [ ] left side [ ] right side Were you the: [ ] driver [ ] front passenger [ ] back seat /drivers side [ ] back seat/passenger side [ ] other: Did you feel pain immediately after the accident? [ ] Yes [ ] No If YES, please explain: Were you wearing your seat belt? [ ] Yes Did the airbag deploy? [ ] Yes [ ] No [ ] No Were you looking straight ahead at impact? [ ] Yes [ ] No If NO, please explain: Were you treated after the accident? [ ] Yes [ ] No Where? If So, what treatment was given? Was a Doctor consulted after the accident? [ ] Yes [ ] No If So, Who was the Doctor? What treatment was given? When was the last time you received treatment for this accident? Are you presently able to work? [ ] Yes [ ] No Automobile Accident Questionnaire (cont.)

4 Please answer ALL questions completely Please explain in full detail how this accident happened? Please list all of your complaints/injuries: Have you ever had these complaints before? [ ] Yes [ ] No If YES, please explain: Is this your first accident? [ ] Yes [ ] No If NO, please list the dates : #1. When? #2. When? #3. When? #4. When?

5 GENERAL SYMPTOM SURVEY NAME: DATE: ************************************************************************ HEADACHES: Mild Moderate Severe (10 = Severe) Description of pain: [ ] Sharp [ ] Dull [ ] Throb [ ] Ache [ ] Pressure Location: [ ] Front [ ] Rt. Side [ ] Lt. Side [ ] Back [ ] Top [ ] Behind Eyes Duration: [ ] Constant [ ] Off and On How Often? times per [ ] day [ ] week ************************************************************************ NECK: Mild Moderate Severe ( 10 = Severe) [ ] Stiff/ Tight [ ] Ache/Sore [ ] Sharp [ ] Burn [ ] Throb [ ] Tingling [ ] Dull Location: [ ] Right side [ ] Left Side [ ] Both Duration: [ ] Constant [ ] Off/On Pain /Tingling/Numbness: [ ] Rt. Shoulder [ ] Rt. Forearm [ ] Rt. Hand [ ] Fingers [ ] Lt. Shoulder [ ] Lt. Forearm [ ] Lt. Hand [ ] Fingers ************************************************************************ MID-BACK: Mild Moderate Severe ( 10 = Severe) [ ] Stiff/Tight [ ] Ache/Sore [ ] Sharp [ ] Burn [ ] Throb [ ] Tingling [ ] Dull Location: [ ] Rt. Side [ ] Lt. Side [ ] Both Duration: [ ] Constant [ ] Off/On ************************************************************************ LOW BACK: Mild Moderate Severe ( 10 = Severe) [ ] Stiff/Tight [ ] Ache/Sore [ ] Sharp [ ] Burn [ ] Throb [ ] Tingling [ ] Dull Location: [ ] Rt. Side [ ] Lt. Side [ ] Both Duration: [ ] Constant [ ] Off/On Pain/Tingling/Numbness: [ ] Rt. Thigh [ ] Rt. Knee [ ] Rt. Calf [ ] Rt. Foot [ ] Toes [ ] Lt. Thigh [ ] Lt. Knee [ ] Lt. Calf [ ] Lt. Foot [ ] Toes ************************************************************************ HIPS/BUTTOCKS: Mild Moderate Severe (10 = Severe) [ ] Stiff/Tight [ ] Ache/Sore [ ] Sharp [ ] Burn [ ] Throb [ ] Tingling [ ] Dull Location: [ ] Rt. Side [ ] Lt. Side [ ] Both Duration: [ ] Constant [ ] Off/On ************************************************************************ KNEES: Mild Moderate Severe (10 = Severe) [ ] Stiff/Tight [ ] Ache/Sore [ ] Sharp [ ] Burn [ ] Throb [ ] Tingling [ ] Dull Location: [ ] Rt. Knee [ ] Lt. Knee [ ] Both Duration: [ ] Constant [ ] Off/On ************************************************************************ JAW: [ ]Tight/Stiff [ ]Ache/Sore [ ] Sharp [ ] Popping/Clicking [ ] Right [ ] Left [ ] Both ****************************************************************************** [ ] Nervousness [ ] Irritable [ ] Fatigue [ ] Depression [ ] Sleep Loss [ ] Stress [ ] Dizziness [ ] Fainting [ ] Blurred Vision [ ] Double Vision [ ] Light Sensitivity [ ] Loss of Balance [ ] Hearing Loss [ ] Ringing in Ears [ ] Nervous Stomach [ ] Nausea [ ] Shortness of Breath [ ] Indigestion/Heartburn [ ] Constipation [ ] Diarrhea

6 FLORIDA CHIROPRACTIC CLINICS AUTHORIZATION FOR MEDICAL INFORMATION This authorization of photocopy hereof will authorize you to furnish all information you may have regarding my condition while under your observation or treatment, including the history obtained, x-rays and physical findings, diagnosis, and prognosis. You are authorized to provide information in accordance with the Florida No Fault Auto Insurance Law. Signature Date AUTHORIZATION FOR WAGES AND SALARY INFORMATION This authorization of photocopy hereof, will authorize you to furnish all information you may have regarding my wages or salary while employed by you. You are authorized to provide this with the Florida No Fault Auto Insurance Law. Signature Date PREGNANCY RELEASE FOR X-RAYS I, do hereby state to the best of my knowledge that I am not pregnant and give full permission to FLORIDA CHIROPRACTIC CLINICS, their associates, or assistants to x-ray me. My last cycle began on. Signature Date Witness

7 P. O. Box 7082 Bridgeport, CT MS APPROVED OMB FORM CMS-1500 (08-05)

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9 LIEN, LETTER OF PROTECTION AUTHORIZATION TO RELEASE MEDICAL INFORMATION AUTHORIZATION TO ADMINISTER TREATMENT POWER OF ATTORNEY TO ENDORSE DRAFTS To Whom It May Concern, I hereby authorize and direct you, my attorney, to pay directly to FLORIDA CHIROPRACTIC CLINICS, INC. such sum as may be and owing FLORIDA CHIROPRACTIC CLINICS, INC. for services rendered to me, both by reason of accident or illness, and by reason of any bills that are due to FLORIDA CHIROPRACTIC CLINICS, INC. I hereby further give an irrevocable lien to said FLORIDA CHIROPRACTIC CLINICS, INC. against any and all proceeds of any settlement, judgment, or verdict which may be paid to me as a result of the injuries or illnesses for which I have been treated with FLORIDA CHIROPRACTIC CLINICS, INC. I direct my attorney to notify FLORIDA CHIROPRACTIC CLINICS, INC. of any settlement, judgment, or verdict by certified mail to my physician at FLORIDA CHIROPRACTIC CLINICS, INC.. FLORIDA CHIROPRACTIC CLINICS, INC. will notify my attorney of all amounts due and owing upon request by my attorney. I irrevocably direct my attorney to pay or escrow for payment the total amount due at the time of closing or disbursement for the past consideration of receiving medical services. I also direct my attorney to notify FLORIDA CHIROPRACTIC CLINICS, INC. in case he/she withdraws or is discharged, immediately by certified mail. FLORIDA CHIROPRACTIC CLINICS, INC. have relied on these promises in providing medical services to me. I understand that I remain personally responsible for the total amounts due to FLORIDA CHIROPRACTIC CLINICS, INC. for their services. I further understand and agree that this lien and authorization does not constitute any consideration for FLORIDA CHIROPRACTIC CLINICS, INC. to await payment and they may demand payment from me immediately upon rendering services at their option. I give FLORIDA CHIROPRACTIC CLINICS, INC. power of attorney to endorse any drafts that are made on my behalf for medical/chiropractic services rendered. I authorize FLORIDA CHIROPRACTIC CLINICS, INC. to release any information pertinent to my case to any insurance company, adjuster, or attorney to facilitate collection under this lien and authorization. I agree to indemnify and hold, FLORIDA CHIROPRACTIC CLINICS, INC. harmless form any damages, liabilities, or cause of action. I hereby give permission to the certified technician/physician to administer prescribed diagnostic/musculoskeletal testing procedures by the primary physician as he/she may deem necessary in the diagnosis and/or treatment of my condition. Dated this day of 20. Signature of Policy Holder Signature of Claimant, if other than Policy Holder Please Print Name Witness STATE OF FLORIDA, COUNTY OF The foregoing instrument was acknowledged before me this day of, 20, by who is personally known to me or who provided as identification. Notary Public, State of Florida My commission No: Print Name My Commission Expires:

10 FLORIDA CHIROPRACTIC CLINICS, INC. Date: Patient: Claim #: DOA: RE: COST OF SINGLE-USE ELECTRIC STIMULATION PADS This letter is an explanation of our billing for single-use electrical stimulation pads. The pads are utilized for sanitary purposes in the treatment of conditions requiring the use of electrical stimulation. Specifically, the electrical stimulation utilized is a form of Galvanic electrical stimulation. Galvanic stimulation produces a strong polar effect, in which a net ion transfer is produced. This ion transfer poses a risk of cross contamination between patients, if the same set of pads is utilized. It is for this reason, that I do not use the multi-use electrical pads, as used in other electrical stimulation applications. The pads utilized are designed specifically for single use only. If you are going to deny re-imbursement for these single-use electrodes, then I am requesting a written acknowledgement of the sanitary considerations and risks of using alternative electrical stimulation pads on more than one patient.. Dr. Gregory A. Yingling

11 FLORIDA CHIROPRACTIC CLINICS, INC Seminole Blvd. Ste. A & B St. Petersburg, Fl Ph: (727) / Fax: (727) POWER OF ATTORNEY AND MEDICAL RELEASE POWER OF ATTORNEY TO ENDORSE CHECKS AND/OR TO SIGN ANY PIECE OF PAPER WHICH WILL ENHANCE OR EXPEDITE PAYMENT TO PROVIDER FOR SERVICES RENDERED, INCLUDING BUT NOT LIMITED TO A RELEASE OF MEDICAL RECORDS AND ASSIGNMENT OF BENEFITS/AUTHORIZATION TO PAY. Know by all these present that: The undersigned has made, constituted and appointed, and by these presents does hereby make, constitute and appoint FLORIDA CHIROPRACTIC CLINICS, INC and any of it s duly authorized agents and employees as and to be the undersigned s true and lawful attorney for and in the undersigned s name, place and stead to endorse any and all checks, drafts, money orders which are made payable to the undersigned alone or to the undersigned and the said FLORIDA CHIROPRACTIC CLINICS, INC. which checks, drafts or money orders are made payable for services which have been made by FLORIDA CHIROPRACTIC CLINICS, INC. at the request or with the knowledge and approval of the undersigned and /or the maker of the check, draft, or money order. Furthermore, the undersigned allows FLORIDA CHIROPRACTIC CLINICS, INC. or any of it s agents to sign any paper that will be necessary to enhance, expedite, and /or allow payment to said provider. This may include affidavits of non-ownership of vehicles, insurance forms and other statements. The undersigned by these presents does give and grant the said FLORIDA CHIROPRACTIC CLINICS, INC. as attorney the full power and authority to do and perform all and every act whatsoever requisite and necessary to be done in and about the premises as fully to all intents and purposes as the undersigned might or could do to personally present insofar as the endorsing and cashing of said checks are concerned as well as any other document. MEDICAL RELEASE A photocopy of this document shall be sufficient to authorize any person having records of medical treatment, services, or supplies pertaining to me to release true copies of same to FLORIDA CHIROPRACTIC CLINICS, INC. or any insurer providing coverage to me in connection with the processing of any claim for benefits made by me or by the assignee herein. A photocopy of this document shall be as binding as an original signature page. The undersigned does hereby ratify and confirm any and all actions taken by the said attorney in accordance with this special power and which the said attorney shall do or cause to be done by virtue of these presents. ASSIGNMENT OF BENEFITS I, Hereby authorize (Name of Insured/Patient) (Name of Insurance Carrier) to make medical benefits payments otherwise payable to me for services rendered by FLORIDA CHIROPRACTIC CLINICS, INC. but not to exceed the charges of those services, payable to mailed directly to: FLORIDA CHIROPRACTIC CLINICS, INC Seminole Blvd. Ste. A & B Seminole, Fl Furthermore, I hereby IRREVOCABLY ASSIGN to FLORIDA CHIROPRACTIC CLINICS, INC. the rights and benefits under any policy of insurance, indemnity agreement, or any other collateral source as defined in Florida Statues for any service and or charges provided by FLORIDA CHIROPRACTIC CLINICS, INC.. IN WITNESS WHEREOF the undersigned have hereunto set their hands, this day of, 200. PATIENT S SIGNATURE PATIENT S NAME ( PLEASE PRINT)

12 FLORIDA CHIROPRACTIC CLINICS DISCLOSURE OF SERVICES FLORIDA CHIROPRACTIC CLINICS, Inc. may provide Chiropractic care, Physical Therapy, Acupuncture Services, Massage Therapy Services, T.M.J. Diagnostic Services, and M.R.I. Services (M.R.I. services are provided by any M.R.I. facility seen fit or any other contracts that may be procured in the future under FLORIDA CHIROPRACTIC CLINICS.) FLORIDA CHIROPRACTIC CLINICS may offer Neurological Exams, Neurological Services, Internal Medicine Exams and any other medically related services. Your physician at FLORIDA CHIROPRACTIC CLINICS may deem one of the aforementioned services outside of what FLORIDA CHIROPRACTIC CLINICS has to offer. FLORIDA CHIROPRACTIC CLINICS can assist you by providing a list of facilities for you to review or you can seek a facility of your choice. Patient Signature Date Print Name Guardian Signature if Patient is a Minor Date Print Name (Guardian) Witness

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