MVA Accident Questionnaire

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1 MVA Accident Questionnaire Name Date Date of Accident Time of Accident Road conditions at time of accident Were you the driver? Were you the passenger? Where were you seated in the vehicle? FRONT BACK LEFT RIGHT Were you transported by Ambulance? Were you seen in the Emergency Room? Were you admitted to the Hospital? Were X-rays or an MRI done? Patient Car Year Make Model Speed Other Car Year Make Model Speed Please draw your accident Please describe your accident Describe your injury (injuries)

2 PLEASE PRINT CLEARLY Name If married, Maiden Name Social Security # Date of Birth month day year Marital Status (circle one) married single domestic partner Gender male female Race Ethnicity Languages spoken Home address City State Zip Mailing Address (if different) City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( ) Personal Pharmacy Phone Who referred you to Dr. Zegarelli? Responsible Party on this account self other If Other: Name Relationship to Patient Mailing Address City State Zip Phone ( ) Emergency Contact responsible party other If Other: Name Relationship to Patient Mailing Address City State Zip Phone ( ) Primary Insurance Co. Plan Name Plan Type Group Name Group # Policy # (ID #) Start/Effective Date Office Copay $ Lawyer s Name Phone The reason for my visit today is: (circle one) Medical Auto accident Worker s Comp Other Have you had the following: NO WANT IT Flu shot Pneumonia shot Hepatitis B Vaccine Shingles vaccine Other List the medications you are taking: Prescription: Over the Counter: Vitamins/Herbs/Minerals/Other:

3 Current Problems: (Please list all current problems you are experiencing. List the most severe first, the second most severe next, etc.) Problem Date of Onset Do you have, or have you ever had, any of the following? (check all that apply) head trauma blindness, cataract, glaucoma trouble hearing, hearing aids allergic rhinitis, sinus infections dentures heart problems, angina, murmur high blood pressure, low blood pressure aneurysm asthma bronchitis, pneumonia, COPD, emphysema cirrhosis, gallbladder disease GERD, Heartburn, hiatal hernia, ulcer hepatitis, jaundice hemorrhoids hernia incontinence kidney disease, UTI STDs arthritis, gout, muscular injury, skeletal injury dermatitis, moles, psoriases epilepsy, seizures stroke, TIA severe headaches, migraines bipolar disorder depression hallucinations, delusions thoughts of suicide, suicide attempts goiter cholesterol problems, thyroid problems high blood sugar, diabetes, low blood sugar anemia cancer HIV TB Other Surgeries: Type Year Hospitalization History: Year Length of Stay Reason Do you use tobacco? Do you drink alcohol? Do you use illicit drugs? Do you eat healthy meals? Do you regularly exercise? Do you take daily aspirin? Does your home have Smoke detectors? Do you keep firearms in your home? Do you wear seatbelts? Have you had exposure to STDs? So you practice safe sex? If female: Date of onset of last mensus Have you ever been pregnant? Have you given birth? Have any of your family had any of the following? arthritis asthma bleeding disorder heart disease diabetes high cholesterol hypertension lung disease mental illness osteoporosis stroke Cancer if yes, what type? other List all allergies (if none, check the blank below): No known allergies Medications Foods Other I acknowledge that I have been provided KPMC s Notice of Privacy Practices Signature of Patient or Personal Representative Date

4 Name Date No Show and Cancellation Policy I understand that if I fail to show up for my appointment without 24 hours notice I may be subject to a No Show fee that is not billable to insurance. I also understand that if I fail to show up for my appointment without notice of cancellation 3 times, any future appointments will be made when the appointment is pre-paid. This is non-refundable and will NOT be credited to future appointments. Financial Policy I understand that charges incurred for services rendered by Kiest Park Medical Clinic or are my responsibility, regardless of insurance coverage. I understand and agree that insurance policies are an agreement between the insurance carrier and me; and not between my insurance carrier and Kiest Park Medical Clinic or. Furthermore, I understand KPMC/SLMC will prepare any necessary reports and forms to assist in making collections from my insurance company and that any amount authorized to be paid directly to KPMC/SMLC will be credited to my account upon receipt. Assignment will be accepted for all insurance with which KPMC/SMLC participates. It is my responsibility to provide this office with accurate insurance information and to notify KPMC/SLMC of any changes in health insurance coverage. If I have any questions on network status/participation with my insurance, it is my responsibility to contact the customer service number on my insurance card. I understand if any insurance company sends a check or reimbursement to me; THE CHECK DOES NOT BELONG TO ME. I am to bring the check and Explanation of Benefits to KPMC/SMLC. Patient Responsibility: If my insurance has an office co-payment, co-insurance, or deductible that has not been satisfied, I must pay this at the time of my appointment. I understand that charges for professional services rendered are due and payable immediately. Any amount unpaid by my insurance company is my responsibility and is due immediately upon notification of the denial by my insurance company. I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. All cost for my care is my responsibility. I agree that I will be responsible for all attorney and legal fees if legal action becomes necessary to collect. Billing: Know your insurance policy I understand that I am responsible for any rejected claims, non-covered expenses, deductibles, co-insurance/copayments. Cash, money order, Visa and Master Card are acceptable means in which to pay the balance. I understand that at times, no matter how diligent KPMC/SLMC s billing might be, my insurance company might decline a claim for services. In that event, it is most effective for me to contact the insurance company since I am their paying customer. KPMC/SLMC s billing department will be glad to assist me, but I may be asked to intervene as that is the most effective means of settling disputes with my insurance company. If there remains an unpaid balance and I make no payment or make no contact as the responsible party despite all KPMC/SLMC s efforts to contact me, then my account could be turned over to a collection agency or pursued legally. Informing our patients about our financial policy assists us in providing the best service to our patients. Thank you for taking the time to read this policy statement. Should you have further questions or comments, please kindly contact our Business Office Supervisor. I hereby understand the financial policy of this practice. I guarantee payment of all charges incurred for the account of the patient named below. I further agree to pay any attorney s fees, court costs, and related collection fees incurred. I also agree that my employer may be contacted to verify employment status. Patient name/signature Date Guarantor/Responsible Party Signature Date

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8 To: Patient Release of Medical Records Form (Please Print or Type) Name of Clinic/Physician Address Phone# Fax # Patient's Name: request and give my permission to release my Medical Records for the time period dating from to The Medical Records as listed above are to be released to: 4230 W Green Oaks Blvd Arlington, TX Fax: Printed Patient Name Date of Birth Social Security # Patient s Signature Today's Date

9 Motor Vehicle Accident Financial Information Form Have you contacted a lawyer? If yes, lawyer s name Lawyer phone number Lawyer Address Do you have a Letter of Protection? If yes, you must present a Letter of Protection during your first office visit. Will your auto insurance be billed for this accident? Have you filed a claim? Name of Insurance Company Claim # Adjustor's Name Adjustor's Phone Number Is anyone else responsible for your charges? If yes, whom? Address Phone # Have you seen any other doctor, hospital, Emergency Room, Clinic, or other medical professional or facility in relation to this accident? If YES, whom/where? Date(s) you were seen

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