Application for Benefits Personal Injury Protection

Size: px
Start display at page:

Download "Application for Benefits Personal Injury Protection"

Transcription

1 Application for Benefits Personal Injury Protection To enable us to determine if you are entitled to benefits under the Personal Injury Protection Law (and/or No-Fault Law), please complete this form and return in promptly. To: Claims Department YOUR NAME: HOME PHONE BUSINESS PHONE ADDRESS (NO., STREET, CITY/TOWN, STATE AND ZIP CODE) DOB SS# PERMANMENT ADDRESS, IF DIFFERENT HOW LONG HAVE YOU LIVED AT THAT ADDRESS? DATE & TIME OF ACCIDENT PLACE OF ACCIDENT (STREET, CITY/TOWN AND STATE) BRIEF DESCRIPTION OF ACCIDENT AND VEHICLES INVOLVED: AT TIME OF ACCIDENT: Were you the driver of our policyholder s car? YES OR NO Were you a passenger in our policyholder s car? YES OR NO Were you a pedestrian? YES OR NO Are you a member of our policyholder s household? YES OR NO IF yes, what is your relationship? AS A RESULT OF THIS ACCIDENT WERE YOU INJURED? YES OR NO IF YOUR ANSWER IS YES, COMPLETE THE REST OF THIS FORM. IF NO, SIGH HERE AND RETURN THIS FORM TO US. SIGNATURE: DESCRIBE YOUR INJURY DATE: HAVE YOU EVER HAD SAME OR SIMILAR CONDITIONS: YES OR NO IF YES, STATE WHEN AND DESCRIBE: IS CONDITION SOLELY A RESULT OF THIS ACCIDENT? YES OR NO IT NO, EXPLAIN: WERE YOU TREATED BY A DOCTOR? DOCTOR S NAME AND ADDRESS YES OR NO IF YOU WERE TREATED IN A HOSPITAL, WERE YOU AN IMPATIENT OR AN OUTPATIENT HOSPITAL S NAME AND ADDRESS AMOUNT OF MEDICAL BILLS TO DATE WILL YOU HAVE MORE MEDICAL EXPENSES? AT THE TIME OF YOUR ACCIDENT, WERE YOU IN THE COURSE OF YOUR EMPLOYMENT? YES OR NO C-258 (6-95) NS

2 Date Insurance Co. Patient ID# Group #: Address City/State/Zip: Address City/State/Zip: Sex: M F Age Birthdate Your SS# Single Married Widowed Separated Divorced Relationship to subscriber: Driver's License # Subscriber's Name Subscriber's Birthdate Would you like to receive our Health Newsletter Yes No Subscriber's SS# Occupation Is patient covered by additional insurance? Yes No Employer Insurance Co. Employer Address ID #: Group #: Employer Phone ext. Customer Service Phone # Spouse's Name Spouse's Birthdate Spouse's Occupation PATIENT INFORMATION SS# Spouse's Employer Whom may we thank for referring you? CHIROPRACTIC REGISTRATION AND HISTORY INSURANCE ASSIGNMENT AND RELEASE I, the undersigned certify that I (or my dependent) have insurance coverage with and assign directly to Dr. Allen Knecht all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions. Responsible Party Signature Relationship Date Cell Home Is condition due to an accident? Yes No Date Best time and place to reach you Type of accident: Auto Work Home Other: IN CASE OF EMERGENCY, CONTACT To whom have you made a report of your accident? Name Relationship Auto Insurance Employer Worker Comp. Other: Home Phone Cell Phone Attorney Name (if applicable) PATIENT INFORMATION Reason for visit When did your symptoms appear? Is this condition getting progressively worse? Where do you continue to have pain, numbness, or tingling? Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain) Type of pain: Sharp Dull Throbbing Numbness Aching Swelling Burning Tingling Cramps Stiffness Swelling Other: How often do you have this pain? Is it constant or does it come and go? PHONE NUMBERS ACCIDENT INFORMATION (circle each that applies) Does it interfere with your Work Sleep Daily Routine Recreation Activities or movements that are painful to perform: Sitting Standing Walking Bending Lying down *Namasté Integrative Medicine NW Macadam Ave. Suite #307 - Portland, OR (503) *

3 !"#$%&"'(%%$)"*+',*-./01+$.*' Patient Information Today s date: Patient Name: Date of Accident: Time of Accident a.m. p.m. Please describe the accident in your own words: Were you the:!driver!front Passenger!Rear Passenger!Pedestrian How many people were in the accident vehicle? Road/Street Name City/State ACCIDENT SITE Nearest intersection with road/street: Driving Conditions: Dry Wet Icy Other Which directions were you headed? Speed you were traveling? VEHICLE Make and model of the vehicle you were in: Where you wearing a seatbelt? Yes No If yes, what type? Lap Shoulders Was the vehicle equipped with airbags? Yes No If yes, did it/they inflate properly? Yes No Did your seat have a headrest? Yes No If yes, what was the position of the headrest? Low Mid-position High OTHER VEHICLE (if applicable) Make and model of the other vehicle: Which direction was the other vehicle headed: Speed the other vehicle was traveling? IMPACT Did your car impact another vehicle? Yes No Did your car impact a structure? Yes No If yes, explain Did any part of your body strike anything in the vehicle? Yes!No If yes, explain: You were impacted from: Front Rear Left Right Other At the time of the impact, were you: Looking straight-ahead Looking to the right Looking to the left Looking down Looking up Were both hands on the steering wheel? Yes No If no, which hand was which hand was on the wheel? Right Left Was your foot on the break? Yes No Were you: Surprised by the impact Braced for the impact POLICE Did the police come to the accident site: Yes No Were there any witnesses? Yes No Was a police report filed? Yes No Was a traffic violation issued? Yes No If yes, to whom?

4 PATIENT CONDITION Were you unconscious immediately after the accident? Yes No If yes, for how long? Please describe how you felt immediately after the accident: TREATMENT Did you go to the hospital?!yes!no When did you go?!immediately after the accident Next day 2 days or more after the accident How did you get to the hospital?!ambulance!private transportation Name of hospital: Diagnosis: Treatment received: X-Rays taken: SYMPTOMS/INJURIES Have you been able to work since this injury?!yes!no How many days of work have you missed? Prior to the injury were you able to work on an equal basis with others your age? If you have had any of the following symptoms since your injury, please check:!arm/shoulder pain!fee/toe numbness!neck pain!back pain!hand/finger numbness!neck stiff!back stiffness!headaches!shortness of breath!chest pain!irritability!sleep difficulty!dizziness!jaw problems!stomach upset!ear buzzing!leg pain!tension!ear ringing!memory loss!vision blurred!fatigue!nausea Is this condition getting progressively worse?!yes!no!unknown Where do you continue to have pain, numbness, or tingling? Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain) Type of pain:!sharp!dull!throbbing!numbness!aching!shooting!burning!tingling!cramps!stiffness!swelling!other Is this condition getting progressively worse?!yes!no!unknown Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain): How often do you have pain? Is it constant or does it come and go? Does it interfere with your:!work!sleep!daily Routine!Recreation Activities or movements that are painful to perform:!sitting!bending!standing!lying down!walking I certify that the above information is correct to the best of my knowledge. Patient signature Date

5 Namasté Integrative Medicine Allen Knecht, D.C SW Macadam Ave. Ste #307 Ben Narcisi, D.C. Portland, OR P(503) F(503) AutoAccidentInjuries Patient sbillofrights AfteryouhavebeeninjuredinanAutoAccident: ReporttheaccidenttotheAutoInsurancecoveringthecaryouwereinatthattimeoftheaccident. 1. Ifyouwerethedriver:reporttheaccidenttoyourinsurancecompany. 2. Ifyouwereapassenger:makesurethatthecar sownerhasreportedtheaccidenttotheir insurancecompanyandhasmentionedthatyouwereapassengerwhomayhavebeeninjured. Aftertheaccidenthasbeenreported,theinsurancecompanywillsendyouaform,whichiscalledthe PersonalInjuryProtection(PIP)Applicationforbenefits. 1. FilloutthisformandsenditbacktotheinsurancecompanyASAP.YoursignedPIP applicationreleasestheinsurancecompanytostartpayingyourmedicalbills. 2. IfyoudonotfilloutandreturnthePIPformtotheinsurancecompany,themedicalbills willbecomeyourresponsibilitybydefault. 3. MakeacopyofthePIPapplicationforyourrecords.Thetreatingdoctorwillalsorequirea copyofthepipapplication. StandardprocedureinthisclinicistobillYOURAutoInsurance(ortheautoinsurancecompanyofthe ownerofthecaryouwerein)forservicesrenderedatthisclinic.thiswillensurethatmedicalbillsare paidasyouaretreated.thisisstandardprocedureinthestateoforegonevenifyouwerenotatfault. Ifthecarinwhichyouwereridingwasuninsuredatthetimeoftheaccident,pleasediscussthe particularswithourstaff.wewillhelpyoudetermineifathirdpartyinsurancebenefitisavailable. IfyouchoosenottouseyouPIPmedicalcoverage,weexpectpaymentattimeofservice. Everyinsurancecompanyhastherighttohaveanypatientexaminedbyaphysicianoftheirchoice.This iscalledanindependentmedicalexam(ime).pleaseinformthenamastéstaffifyourinsurance companyhasscheduledyouforanime. Anycommunicationreceivedfromtheinsurancecompanyviaphoneorlettershouldbeconveyedto yourtreatingphysician.alwaysgetthenameoftheinsurancerepresentativewithwhomyouhavebeen talkingto. Theinsurancecompanyofthecarthathityounormallypaystherepairorreplacementofyourvehicle. Iftheotherdriverwasuninsuredoryouareconsideredatfault,yourcompanymaybelookedtoforcar repairs. Afteryouaremedicallystationary(nofurtherimprovementexpectedwithtimeortreatment)youmay beapproachedbytheatfaultdriver sinsurancecompanyaboutasettlement.whenasettlementis reached,yourcompanyispaidbackforyourmedicalbillstheypaidout.youmayalsobeeligiblefora painandsufferingcashpaymentalso.youcanreachasettlementonyourownorwithanattorney s help.

6 Namasté Integrative Medicine 5331 SW Macadam Ave. Suite #307 Portland, OR (503) Fax: (503) IRREVOCABLE DOCTOR S LIEN AND ASSIGNMENT OR RIGHT TO RECOVERY In consideration and exchange for not having to immediately pay a debt owed and in consideration for receiving future care at or by the clinic and doctors on whose letterhead this document is printed (hereinafter Clinic ), I, the undersigned, hereby assign and convey to the Clinic a legal and all causes of action or rights of recovery I may have arising out of that certain accident or injuryproducing event which occurred on or about the day of, 20, to the full extent of the cost and treatment provided to me by the Clinic. I hereby authorize and direct my attorney(s) to hold in trust, and to pay directly to the Clinic such sums as may be due and owing the Clinic for treatment and other professionals services rendered me both by reason of this accident and by reason of any other bills that are due the Clinic and to withhold such sums from any settlement, judgment or verdict as may be necessary to adequately pay and protect the Clinic. I hereby further give, grant, and convey a lien on my case to the Clinic against any and all proceeds of any and all causes of action, settlements, judgments or verdicts which may be paid to or through my attorney, or myself, as the result of the injuries or conditions from which I have been treated by the Clinic. I fully understand that I am directly and fully responsible to the Clinic for all bills incurred for services rendered me and that this agreement is made solely for the Clinic s additional protection and in consideration for the Clinic s waiting for payment. I further understand that payment for services rendered by the Clinic is not contingent on any settlement, judgment, or verdict by which I may eventually recover. I am personally responsible for my bills, regardless of the outcome of any legal claim or case. I fully understand that if my attorney(s) does/do not protect the Clinic s interest, the Clinic may require me to make payments on a current basis. The Clinic may also bring a cause of action against my attorney(s) for failing to honor this binding and irrevocable assignment between me and the Clinic. I HAVE READ AND FULLY UNDERSTAND THIS DOCUMENT, AND I AM VOLUNTARILY SIGNING THIS DOCUMENT. I AM DIRECTING MY ATTORNEY(S) TO PROTECT THE CLINIC S AND DOCTOR S INTEREST AT THIS TIME OF SETTLEMENT, AND I AM ASSIGNING AND CONVEYING CERTAIN LEGAL RIGHTS OVER TO THE CLINIC. I ALSO KNOW I MAY NOT REVOKE THIS AGREEMENT AT ANY TIME WITHOUT PRIOR WRITTEN AUTHORIZATION FROM THE CLINIC. I UNDERSTAND THAT, AMONG OTHER THINGS, THIS IS A BINDING AND ENFORCEABLE CONTRACT, ASSIGNMENT, AND LIEN. Patient Name (Print) Patient Signature Date A copy of this shall serve as original

7 Namasté Integrative Medicine 5331 SW Macadam Ave Suite #307 Portland, OR (503) The Rivermead Post Concussion Symptoms Questionnaire After a head injury or accident some people experience symptoms, which can cause worry or nuisance. We would to know if you now suffer any of the symptoms given below. As many of these symptoms occur normally, we would like you to compare yourself now with before the accident. For each one please circle the number closest to your answer. 0= not experienced at all 1= no more of a problem now than before the accident 2= a mild problem now 3= a moderate problem now 4= a severe problem now Compare with before the accident, do you now (i.e. over the last week) suffer from: Headaches 4 Feelings of dizziness 4 Nausea and/or vomiting 4 Noise sensitivity, or easily upset by loud noise 4 Sleep disturbance 4 Fatigue, tiring more easily 4 Being irritable, easily angered 4 Feeling depressed or tearful 4 Feeling frustrated or impatient 4 Forgetfulness, poor memory 4 Poor concentration 4 Taking longer to think 4 Blurred vision 4 Light sensitivity, or easily upset or irritated by bright light 4 Double vision 4 Restlessness 4 Are you experiencing any other difficulties? Some other symptoms of Post Concussion Syndrome include the following: Reading problems, writing problems (writing the wrong letter first), typing problems, inability to remember ATM or other numbers, attention impairment, personality changes, intolerance to heat, intolerance to cold, intolerance to alcohol, and loss of sex drive/libido. Please specify any of theses additional problems you experience, and rate as above Patient Name: Date: King NS, Crawford S, Wenden FJ, Moss NEG, Wade DT. (1995) The Rivermead Post Concussion Symptoms Questionnaire: a measure of symptoms commonly experienced after head injury and its reliability. JNeurol242 :

8 DID YOU LOSE WAGES OF SALARY AS A RESULT OF YOUR INJURY? YES OR NO IF YES, AMOUNT LOST TO DATE: $ WHAT IS YOUR AVERAGE WEEKLY OR SALARY? $ IF YOU LOST WAGES: DATE DISABILITY FROM WORK BEGAN: DATE YOU RETURNED FROM WORK: HAVE YOU RECEIVED OR ARE YOU ELIGIBLE FOR BENEFITS UNDER: ANY WORKER S COMPENSATION LAW? YES OR NO EMPLOYMENT BY U.S. GOVERNMENT? YES OR NO MILITARY SERVICE? YES OR NO LIST NAMES AND ADDRESSES OF YOUR PRESENT EMPLOYERS AN GIVE YOUR OCCUPATION AND DATES O EMPLOYMENT FOR EACH: EMPLOYER AND ADDRESS YOUR OCCUPATION FROM TO EMPLOYER AND ADDRESS YOUR OCCUPATION FROM TO AS A RESULT OF YOUR INJURY HAVE YOU HAD ANY OTHER EXPENSES? YES OR NO IF YES, EXPLAIN: SIGNATURE: DATE: IMPORTANT: 1. TO BE ELIGIBLE FOR BENEFITS, COMPLETE AND SIGN THIS APPLCATION. 2. SIGN AUTHORIZATION(S) BELOW. 3. RETURN PROMPTLY WITH ANY MEDICAL BILLS YOU HAVE REVCEIVED TO DATE. *ATTACH ADDITIONAL SHEET IF MORE SPACE IS NEEDED MEMBER NATIONAL INSURANCE CRIME BUREAU C-258 (6-95) NS AUTHORIZATION FOR MEDICAL INFORMATION This authorization or 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 this information in accordance with the Personal Injury Protection Law (and/or No Fault Law). Signature: Date: AUTHORIZATION FOR WAGE AND SALARY INFORMATION This authorization or 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 information in accordance with the Personal Injury Protection Law (and/or No-fault Law) Signature: Date: C-258 (6-95) NS

9 In order to properly assess your condition, we must understand how much your neck and/or low back problems have affected your ability to manage everyday activities. For each item below, please circle which number closely describes your condition right now. Patient Name: 1. Intensity Functional Rating Index For use with NECK AND/OR LOW BACK PROBLEMS ONLY. Possible 2. Sleeping Possible 3. Personal Care (washing dressing, etc.) Possible 4. Travel (driving, etc.) 5. Work Possible Possible 6. Recreation Possible 7. Frequency of pain Possible 8. Lifting Possible 9. Walking Possible 10. Standing Possible Patient Signature: Date:

10 Namasté Integrative Medicine 5331 SW Macadam Ave. Suite 307 Portland, OR P(503) F(503) Acknowledgement of Receipt of Notice of Privacy Practices This form will be retained in your medical record. NOTICE TO PATIENT We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information. Please sign this form to acknowledge receipt of the Notice. Patient Name: Date of Birth: I acknowledge that I have received and had the opportunity to review the Notice of Privacy Practices on the date below on behalf of Namaste Integrative Medicine. I understand that the Notice describes the uses and disclosures of my protected health information by Namaste Integrative Medicine and informs me of my rights with respect to my protected health information. Patient s Signature or that of Legal Representative Printed Name of Patient or that of Legal Representative Today s Date If Legal Representative, Indicate Relationship 1

11 FOR OFFICE USE ONLY We have made every effort to obtain written acknowledgment of receipt of our Notice of Privacy from this patient but it could not be obtained because: The patient refused to sign. Due to an emergency situation it was not possible to obtain an acknowledgement Communications barriers prohibited obtaining the acknowledgement Other (please specify): Employee Name Today s Date 2

NOVA Pain & Rehab Center Accident Forms. Patient Information

NOVA Pain & Rehab Center Accident Forms. Patient Information NOVA Pain & Rehab Center Accident Forms Patient Information Please provide all information requested. If you have any questions or need help, please call the office (703-535-8887) or see one of the staff

More information

PERSONAL INJURY QUESTIONNAIRE

PERSONAL INJURY QUESTIONNAIRE Dr. John Bellomo Director 6442 Edgewater Drive Orlando, Florida 32810 (407) 295.1077 PERSONAL INJURY QUESTIONNAIRE Name: Date: Cell Phone: Home Phone: Address: City/State/Zip: Email Address: Age Birth

More information

Personal Injury Office Policies Dixon Center for Integrative Health Care 211 Old Hickory Blvd. Nashville, TN 37221 (615) 646-1003

Personal Injury Office Policies Dixon Center for Integrative Health Care 211 Old Hickory Blvd. Nashville, TN 37221 (615) 646-1003 Personal Injury Office Policies Dixon Center for Integrative Health Care 211 Old Hickory Blvd. Nashville, TN 37221 (615) 646-1003 The following information outlines Dixon Center s policies on personal

More information

Personal Injury Questionnaire

Personal Injury Questionnaire Welcome to Chiro Spa, we are looking forward to serving you to a lifetime of wellness. Personal Injury Questionnaire Name Nick Name: Email: Address City State Zip Best two (2) phone numbers to reach you

More information

PI MEDPAY FORM. [J Do I have Medpay? [] How much Medpay do I have? [ ] Do I have primary or excess Medpay? [ ] Adjuster name and phone number

PI MEDPAY FORM. [J Do I have Medpay? [] How much Medpay do I have? [ ] Do I have primary or excess Medpay? [ ] Adjuster name and phone number PI MEDPAY FORM [J Do I have Medpay? [] How much Medpay do I have? [ ] Do I have primary or excess Medpay? [ ] Adjuster name and phone number [] Claim # PERSONAL INJURY QUES1"IONNAIRE Name: ----------------

More information

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

Auto Accident Form. Occupation: #Hours per week currently working Telephone: (360) 694-0300 Fax : (360) 694-0301 1610 C St. Ste. 103 Vancouver, WA 98663 www.vancouverspinalcare.com Auto Accident Form Name: DOB: Date: Address: City: State: Zip Code: Home Phone: Cell Phone:

More information

The Khoury Centre For Chiropractic & Wellness

The Khoury Centre For Chiropractic & Wellness The Khoury Centre For Chiropractic & Wellness 640 Washington Street 116 Mechanic Street, Suite 3 Wassim G. Khoury, D.C. Dedham, MA 02026 Bellingham, MA 02019 Dawn-Marie Khoury, D.C., D.I.C.C.P. (781) 329-3344

More information

ACCIDENT HISTORY QUESTIONNAIRE

ACCIDENT HISTORY QUESTIONNAIRE ACCIDENT HISTORY QUESTIONNAIRE PATIENT INFORMATION Name Date Address City State Zip Code DOB Age SS# Marital Status Sex Male Female How did you hear about the office? Home Phone Work Phone Employer Occupation

More information

Gary E. Lee, D.C. Chiropractic Physician 6216 South Redwood Road, Salt Lake City UT 84123 (801) 974-5555

Gary E. Lee, D.C. Chiropractic Physician 6216 South Redwood Road, Salt Lake City UT 84123 (801) 974-5555 Gary E. Lee, D.C. Chiropractic Physician 6216 South Redwood Road, Salt Lake City UT 84123 (801) 974-5555 General information: Name Today s date of Accident Time of Accident Marital status: r Married r

More information

Dr. Brett Haderlie, D.C. Patient Information (Please Print)

Dr. Brett Haderlie, D.C. Patient Information (Please Print) CONNECT CH I ROPRAC TIC Dr. Brett Haderlie, D.C. Patient Information (Please Print) Thank you for choosing our practice for your chiropractic needs. Name SS/HIC/Patient ID# Address City State Zip Birthdate

More information

Personal Injury Questionnaire

Personal Injury Questionnaire Personal Injury Questionnaire Name Date of Birth Phone Do you want to be contacted via text: Name of cellphone carrier (ie: T-Mobile): Address City State Zip SSN: Weight & Height: Dominant hand: Employer

More information

Auto Accident Injury Package New Patient Forms

Auto Accident Injury Package New Patient Forms Auto Accident Injury Package New Patient Forms The Following Individual Documents have been combined into ONE Auto Accident Injury Package of Downloadable PDF New Patient Forms. New Patient Forms Auto

More information

PERSONAL INJURY PATIENT

PERSONAL INJURY PATIENT PERSONAL INFORMATION PERSONAL INJURY PATIENT NAME DATE FILE # BIRTHDATE ADDRESS CITY STATE ZIP HOME PHONE WORK PHONE SOCIAL SECURITY SPOUSE S FIRST NAME EMERGENCY CONTACT ADDRESS PHONE RELATIONSHIP INSURANCE

More information

MOTOR VEHICLE ACCIDENT QUESTIONNAIRE

MOTOR VEHICLE ACCIDENT QUESTIONNAIRE MOTOR VEHICLE ACCIDENT QUESTIONNAIRE Thank you in advance for taking the time to complete this form, this will help us to better assess all of your pain concerns and provide you with the best treatment.

More information

Motor Vehicle Accident Insurance Information

Motor Vehicle Accident Insurance Information AUTOMOBILE ACCIDENT OFFICE POLICY If you have been injured or suspect you have been injured during an automobile accident you must tell your insurance company within seven days of the occurrence of a motor

More information

PERSONAL INJURY QUESTIONNAIRE

PERSONAL INJURY QUESTIONNAIRE PERSONAL INJURY QUESTIONNAIRE NAME: PHONE: ( ) ADDRESS: CITY/STATE/ZIP: AGE: BIRTHDATE: SEX: SS # EMPLOYER'S NAME/ADDRESS: YOUR INSURANCE CO: POLICY #: AGENT'S NAME & PHONE: NAME ON POLICY (IF OTHER THAN

More information

Auto Accident Questionnaire

Auto Accident Questionnaire Auto Accident Questionnaire Please complete all of the following questions regarding your accident. These details are very important, and the doctor will use them with his examination and final care plan.

More information

Family First Chiropractic & Wellness Center 9430 Clairemont Mesa Blvd., Suite E San Diego, CA 92123

Family First Chiropractic & Wellness Center 9430 Clairemont Mesa Blvd., Suite E San Diego, CA 92123 PATIENT NAME: DATE: ADDRESS: CITY: STATE/ZIP CODE: HOME PHONE NUMBER: CELL PHONE NUMBER: SOCIAL SECURITY NUMBER: DATE OF BIRTH: AGE: GENDER: EMERGENCY CONTACT NAME: EMERGENCY CONTACT PHONE NUMBER: EMPLOYER

More information

Personal Injury Intake Form

Personal Injury Intake Form Personal Injury Intake Form Patient Information: Name Home Phone Address Work Phone Cell Phone Date of Birth Social Security # Sex Male Female Height Weight lbs Occupation Marital Status Employer No of

More information

PERSONAL INJURY/AUTOMOBILE ACCIDENT FINANCIAL POLICY

PERSONAL INJURY/AUTOMOBILE ACCIDENT FINANCIAL POLICY PERSONAL INJURY/AUTOMOBILE ACCIDENT FINANCIAL POLICY Our Personal Injury/Automobile Insurance Assignment Program is designed to render you immediate care and keep your out-of-pocket expenses to a minimum.

More information

Insurance (Let us make a copy of your insurance card and you can skip this section)

Insurance (Let us make a copy of your insurance card and you can skip this section) Today s Date: Name: What do you prefer to be called: Male / Female (please circle) Birth Date: Mailing Address: City: State: Zip: Home Phone: Cell Phone: Email: Referred By: Employer: How long employed:

More information

Patient Questionnaire Auto-Collision

Patient Questionnaire Auto-Collision Patient Questionnaire Auto-Collision Patient Name: (First) (Middle) (Last) (Suffix) Today's Date: / / Birth Date: / / Age: SSN: Gender: (circle) F M Height: ft in Weight: lbs (circle one) Right handed

More information

Auto Accident Questionnaire

Auto Accident Questionnaire Auto Accident Questionnaire Patient s Name: Date Of Accident: Date: Social History: (please complete the following, check all boxes that apply) Are you: Married Single Divorced Widowed # of Children: #

More information

Motor Vehicle Accident Intake Form

Motor Vehicle Accident Intake Form 2100 SE Lake Rd Ste 1 Milwaukie OR 97222 Motor Vehicle Accident Intake Form Today's Date: About You Name: Gender: Male Female Address: City: State: Zip: Home Number: Work Number: Other Number: Email Address:

More information

PHENIX CITY SPINE & JOINT CENTER

PHENIX CITY SPINE & JOINT CENTER PHENIX CITY SPINE & JOINT CENTER Name: Street Address: Please list ALL medications City: State: Zip: Home Phone: Cell #: Name Of Medication Dosage/ Strength Frequency Date Started Cell Phone Carrier: Race:

More information

20. Please describe any pain or symptoms: a. DURING the accident: b. IMMEDIATELY AFTER the accident: c. LATER THAT DAY: d.

20. Please describe any pain or symptoms: a. DURING the accident: b. IMMEDIATELY AFTER the accident: c. LATER THAT DAY: d. Name Date of Birth Phone Address City State Zip Email: Employer s Name Employer s Address Your Ins. Co. Claim # Claims Adjustors Name Driver/Owner Have you retained an attorney? ( ) Yes ( ) No If yes attorney

More information

FLORIDA CHIROPRACTIC CLINICS PIP New Patient Information Packet

FLORIDA CHIROPRACTIC CLINICS PIP New Patient Information Packet 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 [ ]

More information

ASSIGNMENT OF BENEFITS FOR DIRECT PAYMENT TO DOCTOR Private, Group, Accident and Health Insurance

ASSIGNMENT OF BENEFITS FOR DIRECT PAYMENT TO DOCTOR Private, Group, Accident and Health Insurance ASSIGNMENT OF BENEFITS FOR DIRECT PAYMENT TO DOCTOR Private, Group, Accident and Health Insurance Accordance to legislation Bill HB1165-Bill 10-16-106.7, assignment of health insurance benefits Concerning

More information

Claim Information. Company Phone # Property Claim # Personal Injury Claim # Personal Injury phone w/ Extension Personal Injury Fax # Mailing Address:

Claim Information. Company Phone # Property Claim # Personal Injury Claim # Personal Injury phone w/ Extension Personal Injury Fax # Mailing Address: Page 1 of 12 Claim Information Date of Accident Primary(Your Insurance) Company Phone # Property Claim # Personal Injury Claim # Personal Injury phone w/ Extension Personal Injury Fax # Mailing Address:

More information

PERSONAL INJURY QUESTIONNAIRE. NAME: Date of Accident

PERSONAL INJURY QUESTIONNAIRE. NAME: Date of Accident PERSONAL INJURY QUESTIONNAIRE NAME: Date of Accident Where did accident happen? Describe the accident in your own words: What was your position in the car? Driver: if Driver were your hands on the steering

More information

CHAMBERS MEDICAL GROUP 5108 15th Street East, Suite 205 * Bradenton, FL 34203 * (941) 727-9057 * (941) 727-3981 fax

CHAMBERS MEDICAL GROUP 5108 15th Street East, Suite 205 * Bradenton, FL 34203 * (941) 727-9057 * (941) 727-3981 fax CHAMBERS MEDICAL GROUP 5108 15th Street East, Suite 205 * Bradenton, FL 34203 * (941) 727-9057 * (941) 727-3981 fax PERSONAL INFORMATION: PLEASE PRINT MISS/MRS/MS/MR: AGE: FIRST MIDDLE MAIDEN LAST DATE

More information

MANHATTAN ORTHOPEDIC & SPORTS MEDICINE GROUP, PC

MANHATTAN ORTHOPEDIC & SPORTS MEDICINE GROUP, PC MANHATTAN ORTHOPEDIC & SPORTS MEDICINE GROUP, PC Edmond Cleeman, M.D. Craig DuShey, M.D. Marvin S. Gilbert, M.D. Richard S. Gilbert, M.D. Mark J. Klion, M.D. Vikas Varma, M.D. 1065 Park Avenue New York,

More information

*Date of injury/auto Accident/Slip and fall: / / Time: : AM PM

*Date of injury/auto Accident/Slip and fall: / / Time: : AM PM Oasis Chiropractic Injury/ Auto Accident/ Slip & Fall Form First Name: Last Name: Title: (check one) Mr. Mrs. Ms. Miss Dr. Other Patient ID#: Single Married Widowed Under 18 (Minor) Separated Divorced

More information

Name: Sex: Male Female. Address: Apt#: Home #: ( ) Cell #: ( ) Other: ( ) DOB: Age: S.S. No. E-mail: Employer: Business # ( ) Occupation:

Name: Sex: Male Female. Address: Apt#: Home #: ( ) Cell #: ( ) Other: ( ) DOB: Age: S.S. No. E-mail: Employer: Business # ( ) Occupation: You deserve to be healthy. Life is a miracle and so are you. When you were created, you were given all the blue-prints, intelligence, tools, and systems to live an active healthy life. Unfortunately, your

More information

BIRTHDATE - - AGE SEX EMERGENCY CONTACT PHONE( )

BIRTHDATE - - AGE SEX EMERGENCY CONTACT PHONE( ) PATIENT INFORMATION SOCIAL SECURITY # MARRIED SINGLE WIDOW DIVORCED NAME Last First MI HOME ADDRESS BILLING ADDRESS ACCT# DRIVER S LICENSE# BIRTHDATE - - AGE SEX CITY STATE ZIP CITY STATE ZIP PHONE HOME(

More information

PATIENT INFORMATION. We will not share your information. Occupation/Job: Employer: Work Address: City, State, Zip EMERGENCY CONTACT INFORMATION

PATIENT INFORMATION. We will not share your information. Occupation/Job: Employer: Work Address: City, State, Zip EMERGENCY CONTACT INFORMATION PATIENT INFORMATION Date of Birth: Sex: M F Age: Soc. Sec. #: - - Photo ID #: State: Address: City, State, Zip: Mobile Phone: Home Phone: Work Phone: Email address: I want to be notified of appointments

More information

MOTOR VEHICLE COLLISION/PERSONAL INJURY QUESTIONNAIRE

MOTOR VEHICLE COLLISION/PERSONAL INJURY QUESTIONNAIRE MOTOR VEHICLE COLLISION/PERSONAL INJURY QUESTIONNAIRE Please answer all questions completely: 1. Your name and address: 2. Phone Number: 3. In your own words, please describe the accident: 4. Where did

More information

Patients Signature Date. Guardian or Spouse s Signature who authorize care. Phone#: Relationship Phone#:

Patients Signature Date. Guardian or Spouse s Signature who authorize care. Phone#: Relationship Phone#: Hands On Chiropractic I understand and agree that health and insurance policies are an arrangement between an insurance carrier and my self. Furthermore, I understand Hands On Chiropractic will prepare

More information

PATIENT INFORMATION INSURANCE INFORMATION

PATIENT INFORMATION INSURANCE INFORMATION PATIENT INFORMATION NAME DATE ADDRESS CITY ST ZIP PHONE(H) (C) (W) DATE OF BIRTH EMAIL AGE SEX: M F SS#(optional) EMPLOYER OCCUPATION ARE YOU CURRENTLY: MARRIED PARTNERED DIVORCED WIDOWED SINGLE SPOUSE/PARTNER

More information

Patient Name: Date of Birth: / / Last First Middle I. Home #: Cell #: Work #: Email Address: Primary Care Physician: Phone: Insurance ID #: Group #:

Patient Name: Date of Birth: / / Last First Middle I. Home #: Cell #: Work #: Email Address: Primary Care Physician: Phone: Insurance ID #: Group #: Patient Name: Date of Birth: / / Race: White Black/African American American Indian/Alaska Native Asian Native Hawaiian/Pacific Islander Other Ethnicity: Not of Spanish/Hispanic Descent Spanish/Hispanic

More information

Accident / Injury Report

Accident / Injury Report Accident / Injury Report Name Date Date of birth Date of accident Time of accident am / pm. Auto injury Were you: Driver Passenger Pedestrian Were you struck from: Behind Right Side Left Side Front Parked?

More information

Automobile Accident Questionnaire. Accident Information. 1. Date of Accident: Time: a.m./p.m.

Automobile Accident Questionnaire. Accident Information. 1. Date of Accident: Time: a.m./p.m. Dr. Paul Sayour and Dr. Michael Preneta Wickford Chiropractic and Wellness Center 610 Ten Rod Road North Kingstown, RI 02852 (401) 295-9767 FAX (401) 295-0230 Automobile Accident Questionnaire Accident

More information

Personal Injury Form TODAY'S DATE: PATIENT INFORMATION Last Name: First Name: MI: Birth Date:

Personal Injury Form TODAY'S DATE: PATIENT INFORMATION Last Name: First Name: MI: Birth Date: ATTORNEY CONCTACT INFORMATION Attorney Name: Office Address: City: State: Zip: Office Phone: Cell Phone: Fax: Attorney Email Address: CASE TYPE Automobile Accident Slip-and-Fall Assault Worker's Compensation

More information

MOTOR VEHICLE COLLISION/PERSONAL INJURY QUESTIONNAIRE

MOTOR VEHICLE COLLISION/PERSONAL INJURY QUESTIONNAIRE MOTOR VEHICLE COLLISION/PERSONAL INJURY QUESTIONNAIRE Please answer all questions completely: 1. Your name and address: 2. Phone Number: 3. Please describe the collision in your own words: 4. Where did

More information

Auto Accident Questionnaire. Auto Insurance Information (please present a copy of your auto insurance card)

Auto Accident Questionnaire. Auto Insurance Information (please present a copy of your auto insurance card) Auto Accident Questionnaire name today s date date of accident date of birth age gender marital status # of children address street city state zip home phone cell phone email occupation company name city

More information

Full Name: Gender M F Age: Birth Date: / / Social Security#: - - Driver s License #: Home Phone: ( ) Employer: Occupation: Work Phone: ( )

Full Name: Gender M F Age: Birth Date: / / Social Security#: - - Driver s License #: Home Phone: ( ) Employer: Occupation: Work Phone: ( ) Personal Injury / Accident Medical History Intake Form Release Chiropractic and Wellness Center Please provide your Driver s License to our staff for your file. ABOUT YOU Full Name: Gender M F Age: Birth

More information

NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS POLICYHOLDER POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER

NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS POLICYHOLDER POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER NEW YORK MOTOR VEHICLE -FAULT INSURANCE LAW APPLICATION FOR MOTOR VEHICLE -FAULT BENEFITS NAME AND ADDRESS OF INSURER * NAME, ADDRESS, AND PHONE NUMBER OF INSURER S CLAIMS REPRESENTATIVE* POLICYHOLDER

More information

Name Last) (First) ( (M.I.) Birth Date Social Security Age Sex: Home Address. City State Zip. Complaint/ Area to be treated Email Address

Name Last) (First) ( (M.I.) Birth Date Social Security Age Sex: Home Address. City State Zip. Complaint/ Area to be treated Email Address PLEASE PRINT CLEARLY : NEW PATIENT FORM Name Last) (First) ( (M.I.) Birth Social Security Age Sex: M / F Home Address City State Zip Complaint/ Area to be treated Email Address Home Phone ( ) Drivers Lic

More information

History Questionnaire

History Questionnaire History Questionnaire Today s Date Physician Patient Information Patient s Name Is this your legal name? Street Address Mr. Miss. Marital Status (circle one) Mrs. Ms. Single Mar Div Sep Wid If not, what

More information

Lighthouse IF YOU WERE THE DRIVER OF YOUR OWN VEHICLE, SOMEONE ELSE S VEHICLE OR A PASSENGER IN THE VEHICLE, ANSWER THIS SECTION COMPLETELY.

Lighthouse IF YOU WERE THE DRIVER OF YOUR OWN VEHICLE, SOMEONE ELSE S VEHICLE OR A PASSENGER IN THE VEHICLE, ANSWER THIS SECTION COMPLETELY. Lighthouse Chiropractic IF YOU WERE THE DRIVER OF YOUR OWN VEHICLE, SOMEONE ELSE S VEHICLE OR A PASSENGER IN THE VEHICLE, ANSWER THIS SECTION COMPLETELY. Your Auto Insurance Company Name Address Policy

More information

To help us provide you the best possible care, please fill out the following information.

To help us provide you the best possible care, please fill out the following information. WELCOME TO OUR TREATMENT CENTER! To help us provide you the best possible care, please fill out the following information. Demographic Information: Name: DOB: Gender: M or F SSN: How long have you lived

More information

PERSONAL INJURY CASE HISTORY

PERSONAL INJURY CASE HISTORY Name: Mowry Chiropractic Inc. 240 North Liberty Street, Powell, OH 43065 (614) 436-9070 (p) ~ (614) 436-8803 (f) PERSONAL INJURY CASE HISTORY 1. Circle the severity (0 = No Pain to 10 = Very Severe Pain)

More information

Accident / Injury Report

Accident / Injury Report Accident / Injury Report Name Date Date of birth Date of accident Time of accident am / pm. auto injury Were you: Driver Passenger Pedestrian Were you struck from: Behind Right Side Left Side Front Parked

More information

Personal Injury Intake Form

Personal Injury Intake Form Personal Injury Intake Form Patient Information: Name Home Phone Address Work Phone Cell Phone Date of Birth Social Security # Sex Male Female Height Weight lbs Occupation Marital Status Employer No of

More information

Potomac Valley Chiropractic Personal Injury

Potomac Valley Chiropractic Personal Injury Potomac Valley Chiropractic Personal Injury Spiro Theodore, D.C. 12105 Darnestown Road, L8 Gaithersburg MD 20878 Please Complete all applicable fields Date: -------------------------------------------------------DEMOGRAPHICS--------------------------------------------------------------

More information

CHIEF COMPLAINT: Please number your symptoms (1 is the most severe) that you have developed since the accident.

CHIEF COMPLAINT: Please number your symptoms (1 is the most severe) that you have developed since the accident. VANCE CHIROPRACTIC PERSONAL INJURY QUESTIONAIRE (PLEASE BE VERY SPECIFIC WITH YOUR ANSWERS THANK YOU!) Last Name First Name Middle Home Phone Work Phone Street Address and Number Mailing Address if Different

More information

Orthopedic Initial Questionnaire

Orthopedic Initial Questionnaire Orthopedic Initial Questionnaire Name: Date: Height: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete

More information

Next Level Physical Therapy PC Patient Information

Next Level Physical Therapy PC Patient Information Next Level Physical Therapy PC Patient Information First Name M.I. Last Name Date of Birth SS# (if minor, leave blank) Student? F/T P/T NO Street Address Billing Address (if different) City State Zip Home

More information

Vehicle Accident Information Form

Vehicle Accident Information Form Vehicle Accident Information Form Patient Name: 1. What was the date of the accident? 2. Approximately what time did the accident occur? : AM / PM 3. How many vehicles were involved in the accident? 4.

More information

Name: Date of Birth: Social Security #: Home # Cell # Address: City: State: Zip: Emergency Contact #: Relationship:

Name: Date of Birth: Social Security #: Home # Cell # Address: City: State: Zip: Emergency Contact #: Relationship: California Back and Pain Specialists 14624 Sherman Way, Suite 309, Van Nuys, CA 91405 1172 Swallow Lane, Simi Valley, CA 93065 101 Hodencamp Road, Suite 103, Thousand Oaks, CA 91360 9201 Sunset Blvd, Suite

More information

Radiologic Consulting. Referral Information

Radiologic Consulting. Referral Information Radiologic Consulting Referral Information John S. Miller, DC, DACBR, PS 9015 Holman Rd NW, Suite 3 Seattle, WA 98117 phone (206) 784-8119 fax (206) 784-4020 Email: jsmiller2@mindspring.com Information

More information

21031 Michigan Avenue Dearborn, MI 48124

21031 Michigan Avenue Dearborn, MI 48124 21031 Michigan Avenue Dearborn, MI 48124 19725 Allen Rd #102 Brownstown, MI 48134 44633 Joy Rd #200 Canton, MI 48187 Phone: 313-277-6700 FAX: 313-277-2483 Date: Dear Patient: An appointment has been scheduled

More information

Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL 60030 Phone: 847-247-7200 Fax: 847-247-4340

Praxis Physical Therapy and Human Performance 935 Lakeview Parkway Suite #195 Vernon Hills, IL 60030 Phone: 847-247-7200 Fax: 847-247-4340 Medical Registration Form (Page 1) Welcome to our Office: By completing this patient information form, you will help us to serve you more efficiently. Should you have any questions concerning our professional

More information

MVA/ PI Registration Form. Is this accident work related? YES or No If yes, stop here and notify front desk for different forms.

MVA/ PI Registration Form. Is this accident work related? YES or No If yes, stop here and notify front desk for different forms. MVA/ PI Registration Form Is this accident work related? YES or No If yes, stop here and notify front desk for different forms. Date: Patient # Patient Name: DOB; Gender: M or F SSN Address: City/State:

More information

J. Richard Lilly, M.D., A.B.F.P., & Associates, P.C.

J. Richard Lilly, M.D., A.B.F.P., & Associates, P.C. J. Richard Lilly, M.D., A.B.F.P., & Associates, P.C. PATIENT REGISTRATION - Please PRINT Clearly Patient Name First Middle Last Date of Birth Age Home Address Apt. No. City State Zip code Occupation Social

More information

Worker s Compensation Intake Form

Worker s Compensation Intake Form Worker s Compensation Intake Form Patient Information: Name Home Phone Address Work Phone Social Security No. Date of Birth Sex Male Female Height Weight lbs Occupation Marital Status Employer No of Children

More information

NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW COVER LETTER POLICYHOLDER POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER

NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW COVER LETTER POLICYHOLDER POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER NEW YORK MOTOR VEHICLE -FAULT INSURANCE LAW COVER LETTER NAME, ADDRESS AND PHONE NUMBER OF INSURER, SELF-INSURER OR REPRESENTATIVE* NAME, ADDRESS AND PHONE NUMBER OF CLAIM REPRESENTATIVE* POLICYHOLDER

More information

Please completely fill out all applicable information. New PI Patient Intake

Please completely fill out all applicable information. New PI Patient Intake Please completely fill out all applicable information New PI Patient Intake Date Pt Name, Last First Mid SS# DOB Address Apt City State Zip Phone Home Work Employer /Occupation Marital Status M / S / D

More information

8. On the picture below, please mark an X over ANY area(s) that ARE or WERE painful

8. On the picture below, please mark an X over ANY area(s) that ARE or WERE painful Worker s Compensation/Injury Questionnaire Please complete all of the following questions regarding your accident. These details are very important, and the doctor will use them with his examination and

More information

Last Name First Name Middle Initial Address Apt # City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( )

Last Name First Name Middle Initial Address Apt # City State Zip Home Phone ( ) Mobile Phone ( ) Work Phone ( ) Patient Registration A. P A T I E N T Please Print Legibly on Form Account # Address Apt # City State Zip DOB (mm/dd/yy) Gender Male Female SSN # Preferred Contact Method: Home Ph Mobile Ph Text E-mail

More information

Blyss Chiropractic, 111 SW Columbia, Suite 100, Portland, OR 97201

Blyss Chiropractic, 111 SW Columbia, Suite 100, Portland, OR 97201 Patient Name: Date of Birth: Page 1 of 7 Patient Name: Date of Birth: Page 2 of 7 Patient Name: Date of Birth: PAIN DRAWING SYMPTOM RATING SCALE Ache

More information

Dr. Paul S. Baird 785 E. 200 S. Ste. 6A, Lehi 801-766-4741. Patient Name: Date of Accident: Time of Accident:

Dr. Paul S. Baird 785 E. 200 S. Ste. 6A, Lehi 801-766-4741. Patient Name: Date of Accident: Time of Accident: Dr. Paul S. Baird 785 E. 200 S. Ste. 6A, Lehi 801-766-4741 Auto Accident Section Patient Name: Date: Date of Accident: Time of Accident: Daylight Dawn Dusk Dark Injury History: Were you: Driver Front Seat

More information

Name. Date of Birth Age Occupation. Chief Complaint Please describe your present complaint(s)

Name. Date of Birth Age Occupation. Chief Complaint Please describe your present complaint(s) Health History 15404 E Springfield Ave Suite 100 Spokane Valley, WA 99037 509.892-9800 Date / / Name Date of Birth Age Occupation Are you here because of: AUTO ACCIDENT? Y / N WORK INJURY? Y / N Chief

More information

ASSIGNMENT OF BENEFITS. CLAIM # Insurance Co. Name + Address INJURY HISTORY. Patient s Name Today s Date

ASSIGNMENT OF BENEFITS. CLAIM # Insurance Co. Name + Address INJURY HISTORY. Patient s Name Today s Date Page 1 out of 7 AUTO INJURY HISTORY FORM Missing / Incomplete / Inaccurate information may jeopardize your coverage by the insurance carrier or future legal documentation ASSIGNMENT OF BENEFITS The information

More information

Auto Accident/Personal Injury Information

Auto Accident/Personal Injury Information Auto Accident/Personal Injury Information Patient s Name: Today s Date: Personal Injury Information Date of Accident: Time of Accident: am/pm Did police arrive on scene? [ ] Yes [ ] No Is there a report?

More information

4765 Carmel Mountain Rd. Ste 202, San Diego, CA 92130 Phone (848) 847-0055 Fax (858) 847-9944

4765 Carmel Mountain Rd. Ste 202, San Diego, CA 92130 Phone (848) 847-0055 Fax (858) 847-9944 4765 Carmel Mountain Rd. Ste 202, San Diego, CA 92130 Phone (848) 847-0055 Fax (858) 847-9944 Dear Patient, Your insurance may pay your total bill for services rendered by Pilates People Torrey Hills.

More information

PROUGH CHIROPRACTIC 3402 Washington Rd., Suite 201 McMurray, PA 15317 PATIENT INFORMATION & CONDITION FORM

PROUGH CHIROPRACTIC 3402 Washington Rd., Suite 201 McMurray, PA 15317 PATIENT INFORMATION & CONDITION FORM Today's Date: / / PROUGH CHIROPRACTIC PATIENT INFORMATION & CONDITION FORM Patient Name: Birth Date: / / Age: Gender: F M CURRENT ADDRESS Street City State Zip Phone ( ) Cell Phone ( ) E Mail Address If

More information

Patient Information: In Case of Emergency: Physician: Insurance:

Patient Information: In Case of Emergency: Physician: Insurance: For office use only: Start of Care: ICD-9 Codes: Patient Information: Name: Address: City: State: IL Zip: Patient of Birth: Policy Holders of Birth: of Injury or Onset of Symptoms: Home Phone: Work Phone:

More information

LAS VEGAS PAIN INSTITUTE & MEDICAL CENTER, L.L.C.

LAS VEGAS PAIN INSTITUTE & MEDICAL CENTER, L.L.C. LAST NAME: FIRST NAME: DOB: / / AGE: MARITAL STATUS: SEX: M F SSN: - - HOME#: CELL#: WORK#: STREET ADDRESS: CITY: STATE: ZIP: EMPLOYER NAME & ADDRESS: SPOUSE S NAME: DOB: / / SSN: - - WORK#: EMPLOYER NAME

More information

MVA Accident Information

MVA Accident Information In this Report MVA Accident Information... 1 Vehicle Information... 3 Vehicular and Patient Relationship.. 4 Facts about the Patient before the MVA Accident... 4 Facts about the Patient during this MVA

More information

Patient Registration/Personal Injury

Patient Registration/Personal Injury Patient Registration/Personal Injury Patient Name: Account #: First Middle Last Address: Street Address City State Zip Home Phone: Work/Cell: SSN: of Birth: Male Female Name of Spouse: Contact Number:

More information

***************PATIENT INFORMATION****************

***************PATIENT INFORMATION**************** SEP BADY, MD ***************PATIENT INFORMATION**************** TODAYS DATE: / / WHICH DOCTOR ARE YOU SEEING? BADY KURUVILLA LIU OTTEN TRAINOR YEE PATIENT LAST NAME: FIRST: MIDDLE INITIAL: ADDRESS: CITY/STATE:

More information

MILLENNIUM PHYSICAL THERAPY & SPORTS MEDICINE

MILLENNIUM PHYSICAL THERAPY & SPORTS MEDICINE A) PATIENT INTAKE/TREATMENT FORM 1) Patient Name: 2) Social Security #: 3) Home Phone number: ( ), Cell: ( ), Work: ( ) 4) Address: City, State, Zip Code 5) Gender: M F 6) Date of Birth (DOB): / / 7) Marital

More information

Dear Participant, If you have any questions, please call the Customer Service Office at 702-733-9938. Sincerely, Culinary Health Fund

Dear Participant, If you have any questions, please call the Customer Service Office at 702-733-9938. Sincerely, Culinary Health Fund 1901 Las Vegas Blvd. So. Suite 107 Las Vegas, Nevada 89104-1309 (702) 733-9938 www.culinaryhealthfund.org Dear Participant, We have been informed that you and/or your dependent(s) have been involved in

More information

Patient Basic Information

Patient Basic Information Patient Basic Information Personal Information: Last Name: First Name: Mid. Init.: Address: City, State, Zip: Home Phone: Work Phone: Social Security No.: Date of Birth: Date of Injury/Onset: Dominant

More information

Family Chiropractic and Wellness Kristie Pszczola, D.C. 104 Mirramont Lake Dr. Woodstock, GA 30189 Thank you for choosing Family Chiropractic and Wellness as your healthcare provider. We are committed

More information

SOUTH COUNTY PHYSICAL THERAPY AND REHABILITATION CENTER, INC.

SOUTH COUNTY PHYSICAL THERAPY AND REHABILITATION CENTER, INC. SOUTH COUNTY PHYSICAL THERAPY AND REHABILITATION CENTER, INC. 6767 9th Avenue Port Arthur, TX 77642 Ph: (409) 985-9365 Fax (409) 985-6315 I consent to treatment and I authorize payment of medical benefits

More information

DEMOGRAPHIC FORM PATIENT INFORMATION. Mailing Address: City & State: ZIP Code: Pharmacy: City: Cross Roads: INSURANCE INFORMATION

DEMOGRAPHIC FORM PATIENT INFORMATION. Mailing Address: City & State: ZIP Code: Pharmacy: City: Cross Roads: INSURANCE INFORMATION DEMOGRAPHIC FORM Today s date: Dr. Doug S. Clouse Dr. Benjamin MacQueen Dr. D. Gregory Stewart Name (Last, First, MI): Home phone no.: Cell phone no.: PATIENT INFORMATION Marital status (circle one) Single

More information

Orthopedic Initial Questionnaire. Date: Weight:

Orthopedic Initial Questionnaire. Date: Weight: Orthopedic Initial Questionnaire Name: Height: Date: Weight: In order to allow the therapist to have a better understanding of the nature of your injury and evaluate your condition fully, please complete

More information

Workman s Compensation

Workman s Compensation Workman s Compensation Name: Sex: Phone Number: Age: Address (Street/City/State/Zip) Name of Employer: Phone: Address of Employer (Street/City/State/Zip) Date and time of accident?: Where were you taken

More information

PATIENT INFORMATION FORM

PATIENT INFORMATION FORM 737 Pearl Street, Suite 108 Phone: 858.456.2114 Fax: 858.456.2103 www.abilityrehabsd.com PATIENT INFORMATION FORM Please print and complete ALL items. If an item doesn t apply, put N/A Patient Name: Age:

More information

Reference #: Date. Received: police report, Last Name. Middle Name. 2. Date of Birth: 4. Social Security. Zip Code. Apt # City. State. State.

Reference #: Date. Received: police report, Last Name. Middle Name. 2. Date of Birth: 4. Social Security. Zip Code. Apt # City. State. State. Michigan Assigned Claims Plan c/o Michigan Automobile Insurance Placement Facility PO Box 532318 Livonia, MI 48153 2318 Phone: 734 464 8111 Internal Use Only Reference #: Date Received: Please note, you

More information

Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D

Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D Be Fit Physical Therapy & Pilates, LTD Patient Registration Form Date: Name: Birthdate: Age: Address: City, State, ZIP: Preferred Phone # (Home)(Cell)(Work): Marital Status: M S W D Secondary Phone# (Home)(Cell)(Work):

More information

Auto Accident Description

Auto Accident Description Automotive Accident Form Billing Information Patient name: Date of injury: Time of injury: AM PM City and street where accident occurred: What is the estimated damage to your vehicle? $ Do you have automobile

More information

Welcome! Please fill out this Patient Registration

Welcome! Please fill out this Patient Registration Welcome! Please fill out this Patient Registration Personal: (Please Print Clearly, Sign ALL pages and be Complete) Last Name First Name Middle Street City State Zip Home Phone #: ( ) Work / Cell Phone

More information

NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW COVER LETTER POLICYHOLDER POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER

NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW COVER LETTER POLICYHOLDER POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER NEW YORK MOTOR VEHICLE -FAULT INSURANCE LAW COVER LETTER NAME, ADDRESS AND PHONE NUMBER OF INSURER, SELF-INSURER OR REPRESENTATIVE* NAME, ADDRESS AND PHONE NUMBER OF CLAIM REPRESENTATIVE* POLICYHOLDER

More information

RIDGEWOOD PHYSICAL THERAPY AND REHABILITATION CENTER PATIENT INFORMATION

RIDGEWOOD PHYSICAL THERAPY AND REHABILITATION CENTER PATIENT INFORMATION RIDGEWOOD PHYSICAL THERAPY AND REHABILITATION CENTER PATIENT INFORMATION Today s date: / / EMAIL: PATIENT INFORMATION Patient s last name: First: Middle: Mr. Mrs. Miss Ms. SS#: - - Birth date: Sex: [ ]

More information

Patient Insurance Information

Patient Insurance Information Improving Lives & Performance Dr. Jeff Eidsvig, D.C., TPI- CGFI 3060 Communications Parkway, Suite #104 Plano, Texas 75093 972-312- 9310 New Patient Information / Change of Information : New Patient Change

More information

City: State: Zip: City: State: Zip: Phone: Birth Date: Age: Marital Status: Single Married Divorced Widowed Cell Phone: City: State: Zip:

City: State: Zip: City: State: Zip: Phone: Birth Date: Age: Marital Status: Single Married Divorced Widowed Cell Phone: City: State: Zip: Name: Mailing Address: First M.I. Last Today s Date: Physical Address: Phone: Birth Date: Age: Marital Status: Single Married Divorced Widowed Cell Phone: Employer: Occupation: Employer s Address: Work

More information

DEL MAR PHYSICAL THERAPY Patient Information

DEL MAR PHYSICAL THERAPY Patient Information PLEASE PRINT CLEARLY DEL MAR PHYSICAL THERAPY Patient Information Name Birthdate Last First M.I. MM/DD/YYYY Age Sex M / F Marital Status SS# Address City Zip Phone ( ) Work ( ) Cell ( ) Email **********************************************************************************

More information