Auto Accident Form. Occupation: #Hours per week currently working

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1 Telephone: (360) Fax : (360) C St. Ste. 103 Vancouver, WA Auto Accident Form Name: DOB: Date: Address: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: How did you hear about us so we can thank them? Occupation: #Hours per week currently working Have you ever been to a chiropractor before? Yes/No My last adjustment was Will you be seeking reimbursement from insurance? Y / N Would you like to check your insurance benefits? Y / N Spouse s name: Spouse Occupation Spouse s #Hours per week currently working Spouse DOB: Number of children: Your position in vehicle: Driver Front Passenger Right rear passenger Left rear passenger Other Please Explain: Involved Party vehicle make: Model: Year: Name of driver: Address of driver: City: State: Zip Code: Involved Party vehicle make: Model: Year: Name of driver: Address of driver: City: State: Zip Code: Has a personal injury protection (PIP) claim been file? Yes: No: If yes, claim #: How much damage was done to the vehicle: $ Have you consulted with an attorney:

2 Is an attorney representing you? If so please provider contact information below: Law Office Name: Attorney Name: Phone number: ( ) Address: City: State: Zip Code: How did you leave the scene of this accident: Drove same vehicle: By ambulance: By fire department: By police: By friend Other: Other: Location of accident: City: County: State: Was this accident investigated by law enforcement: If law enforcement did investigate accident what agency: City police: Country police or sheriff: State police: Case number: Did you complete a state accident form: On below image shade areas of impact on vehicle In below box draw to best abilities the accident scene. What was the approximate speed of the vehicle: Miles Per Hour (MPH) During accident were you wearing a seatbelt and/or shoulder harness: Did a airbag deploy at your position: Was a headrest available at your position: At the time of impact, were you aware that an accident was about to occur: Did you brace for impact: At the time of accident, were you looking: Forward: Right: Left: At the time of accident, were you: Stopped: Moving Forward: Moving Backwards: Did you have a: Traffic light: Stop Sign: Yield Sign: No traffic control: This was a: Head-on collision: Rear-end collision: T-Bone collision: Collision into stationary object: Car-bicycle accident: Car-pedestrian accident: Other-Please explain:

3 Date of accident: Time of accident: AM/PM The weather was: Clear: Cloudy: Foggy: Other: The road condition were: Dry: Wet: Icy: Snowy: The road surface was: Concrete Asphalt Dirt Gravel At the time of the accident, it was: Raining: Drizzling: Snowing: Hailstorm: No precipitation Dry: Did you receive any injuries, bruises, or cuts as a result of the use of seatbelts, shoulder harness, headrest, or airbag deployment? Please describe: Please note on the diagram below any areas of contusions, bruising, cuts, lacerations, or scrapes Did you experience any of the following symptoms after the accident: Loss of consciousness Dizziness Confusion Tingling in arms or legs Numbness in arms or legs Neck Pain Neck Stiffness Low back Pain Low back stiffness Blurred vision Disorientation Warm spots in your body Cold spots in your body Headaches Have you had difficulty with any of the following daily activities since the accident: Sleeping Sitting Walking Eating Bathing Reading Concentrating Bowel movements Please list any other daily activities that have been affected as a result of this accident:

4 How did you leave the scene of this accident: Drove same vehicle: By ambulance: By fire department: By police: By friend Other: Other: Location of accident: City: County: State: Was this accident investigated by law enforcement: If law enforcement did investigate accident what agency: City police: Country police or sheriff: State police: Case number: Did you complete a state accident form: It is of the utmost importance that this form be thoroughly completed. Also, please bring in copies of all reports that were completed either by you or by law enforcement. Print Name: Sign:

5 To Attorney(s) and/or Insurance: Doctor s Lien Derrick Hau, D.C. Kenneth Ransonet, DC. Scott Freeman, D.C. Vancouver Spinal Care 1610 C Street Suite 103 Vancouver, WA phone Patient s Name: fax Date of Birth: I do hereby authorize Derrick Hau, D.C. to furnish to you, my attorney and/or insurance with a full report of his examination, diagnosis, treatment, prognosis, etc., of my self in regard to the accident in which I was recently involved. I hereby authorize and direct you, my insurance company, and/or my attorney to pay directly to said doctor such sums as may be due and owing him for medical service rendered to me both by reason of settlement, judgment, or verdict as may be necessary to adequately protect said doctor. I hereby further give a LIEN on my case to said doctor against any and all proceeds of my settlement, judgment or verdict which may be paid to you, my attorney, or myself as the result of the injuries for which I have been treated or injuries in connection therewith. I agree never to rescind this document and that a rescission will not be honored by my attorney. I hereby instruct that in the event another attorney is substituted in this matter, the new attorney honor this lien as inherent to the settlement and enforceable upon the case as if it were executed by him. I fully understand that I am directly and fully responsible to said doctor for all medical bills submitted by him for service rendered me and that this agreement is made solely for said doctor s additional protection and in consideration of his awaiting payment. I further understand that such payment is not contingent on any settlement, judgment or verdict by which I may eventually recover said fee. If my attorney does not wish to cooperate in protecting the doctor s interest, the doctor will not await payment but may declare the entire balance due and payable. Patient s Signature: Date: Address City St Zip ATTORNEY(S): Please sign, date and return one copy to doctor s office and keep one copy for your records. The undersigned being attorney of record for the above patient do hereby agree to observe all the terms of the above and agrees to withhold such sums form any settlement, judgment or verdict as may be necessary to adequately protect said doctor named. Attorney further agrees that in the event this lien is litigated that the prevailing party will be awarded attorney fees and costs. Attorney Signature: Date:

6 PERSONAL INJURY FINANCIAL POLICY This is an agreement between Vancouver Spinal Care and the Patient/Debtor named on this form. In this agreement the words you, your, and yours means the Patient/Debtor. The word account means the account that has been established in your name to which charges are made and payments are credited. The words we, us, and our refer to Vancouver Spinal Care. Charges to Account: Upon reaching an agreement with your insurance company or attorney, charges may be made to your account without payment at time of service during your personal injury claim. We shall have the right to cancel this privilege at any time if circumstances between this office and your attorney or insurance company change. When appointments are not made and kept according to your treatment plan, you may be released from our care due to non-compliance. Responsibility for Payment As a courtesy to you, we will gladly submit your charges to your insurance company(ies) and/or your attorney; however, all services rendered by this office are charged directly to you, and ultimately, you are personally responsible for payment of these charges, regardless of any insurance reimbursement or settlement you may or may not receive. Effective Date: Once you have signed this agreement, you agree to all of the terms and conditions contained herein and the agreement will be in effect. You may receive a copy of this agreement upon request. Insurance and payments: While you are under care for your personal injury you authorize us to send your records and bills to the appropriate companies. (i.e. auto insurance company or attorney) You authorize your insurance company(s) or attorney to pay benefits directly to Vancouver Spinal Care. If benefits are paid directly to you the patient, payment for your full bill will be expected promptly after your settlement is reached. Any unpaid balance over 120 days post settlement will be transferred to our collections agency. If we refer your account to a collection agency, you agree to pay all of the collection costs that are incurred to you and it will become your responsibility. The insurance company will make the final determination of your eligibility and amount of the settlement. If you disagree with any verification or payment on your behalf, it will be your responsibility to pay your account balance in full. Any discrepancies will be handled between you and your insurance company. Attorney Liens: If you hire an attorney to represent you in a law suit, it is our policy to have your attorney sign a Doctor's Lien. This will guarantee direct payment to our office for any undid balance upon the settlement of your law suit. We retain the right to first submit all charges to your private and/or auto insurance policy for payment. Further, this office does not discount or reduce the amount of your balance based upon the outcome of your settlement. Returned Checks: There will be a $10.00 fee assessed for all returned checks. I have read and understand the financial policy and agree to all terms and conditions stated herein. Patient s Name: Responsible Party (if not the patient): Signature: Date:

7 HIPAA Form Vancouver Spinal Care 1610 C Street Suit 103 Vancouver, Wa Phone Fax HIPAA - Notice of privacy practices In accordance with The Health Information Privacy and Accountability Act (HIPAA), all healthcare providers are required by law to maintain the privacy of your health information and provide you a description of their privacy practices. This notice identifies your rights regarding the center's use of your protected Health Information. This notice also describes how your health information may be used and disclosed, and how you can get access to this information. Each time you visit Vancouver Spinal Care a record of your visit is made. The clinic will use and disclose health information about treatment and services you receive so that we can bill and receive payment. We will also tell your insurance company about treatment you are going to receive to determine whether your plan will cover it. Information about your treatment and services may also be disclosed to your attorney if an attorney is involved in litigation regarding the medical necessity of medical massage and the liability of payment. Although your health record it the physical property of Vancouver Spinal Care, you have the right to inspect and upon written request, obtain a copy for a fee of your health information which usually includes prescriptions and medical and billing records. If you believe that health information we have about you is incorrect or incomplete, you may request in writing that we amend your health information. Our disclosure of your health information is limited to your insurance company, your attorney, your treating physicians, and you. If the patient is a minor or has a legal guardian, a parent or guardian is required to read this notice and sign for the patient, and the patient health information will be disclosed to the parents or guardian. If you believe your privacy rights have been violated, you may file a written complaint to the office of civil Rights in the U.S. Department of Health and Human Services at 200 Independence Avenue SW., Room 509 F, HHH Building, Washington D.C By signing this form you hereby acknowledge that Vancouver Spinal Care may release your Protected Health Information to carry out payment and treatment operations. I have read and understand the Notice of Privacy Practices of Vancouver Spinal Care. Patient/Patient Representative Signature Date:

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