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 Accident Injury IF you are have sustained injuries due to being involved in an Auto Related Accident CLICK the Button Below to Print ALL Forms you will need to Complete for your First Office Visit. Print ALL Required Forms New Patient Health History Pain Description and Location HIPPA Notice of Privacy Assignment of Benefits Auto Accident Injury Report NY State Motor Vehicle No Fault Form Dow Chiropractic believes Your Time is Valuable; therefore, we encourage our New Patients to print and complete the attached PDF forms PRIOR to visiting our office for the first time. This will save both you and us time. Any areas within the forms that you don t understand can be left unanswered to be completed with our office staff s assistance. IF You Have Any Questions Call Us Thomas Dow, D.C., P.C. 631-249-0011 [Auto Accident Injury Package Cover]
New Patient Health History Today s Date Patient Data / / File Number Last Name First Name MI Email Address* * Your email address will NOT be shared with any 3 rd parties. It is only used for occasional office announcements and reminders. Name You Prefer to be Called Male Female Date of Birth Age SSN Employer Occupation Marital Status Spouse s Name Spouse Phone Number of Children Contact Data Address City ST ZIP Home Phone Work Phone Cell Phone Referred By Emergency Contact Phone Reason For Visit Reason Work Auto Sports Sudden Chronic Date of Injury Date Symptoms Appeared Describe What Happened NOTE: Complete Separate Form for Pain Description, Location and Pain Level Is this Condition Getting Worse? Yes No Constant Comes and Goes Does Condition Interfere with Work Sleep Daily Routine Please Explain Have you Experienced the Same or Similar Condition in the Past? Yes No If Yes, When? Please Explain List Other Practitioners Seen for this Condition Previously Treated By a Chiropractor? Yes No If Yes, Whom? Phone Describe Insurance Information (Please Inform Front Desk of 2 nd Insurance Source) Insurance Company Ins. Company Ph # ID #: Company Address Insured s Employer: Insured s Name Relation to you: Group #: Date of Birth Insured s SSN ID #: Doctor s Notes [New Patient Health History Page 1]
Have You Ever Suffered From (Check All That Apply) Habits Review Please place a in the Box that Most Closely Describes Your Level Please list ALL Drugs / Over-the-Counter Meds / Vitamins / Supplements you are Taking with Dosage: Comments: Daily Activities Please Indicate Whether or Not the Following Apply to You: Do you experience pain every day? Yes No Do you exercise? No Yes Are your symptoms worse during certain times of the day? Yes No IF Yes - How Often? Daily 2-3 Times/Week Varies Do your symptoms interfere with daily life? Yes No Has Your Weight Fluctuated in the Past Year? Yes No Do changes in the weather affect your symptoms? Yes No If Yes Up or Down How Much? What activities aggravate your symptoms? What improves your symptoms? Signatures Insured s Name Patient s Signature Spouse or Guardian Signature Date Date I understand and agree that health/accident insurance policies are an arrangement between the insurance carrier and me. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable. Doctor s Notes [New Patient Health History Page 2]
Patient Pain Description - Location - Level Right Left Left Right Front Left Please mark the areas of your medical complaint on the diagram above. Use BOTH of the following Alphabetical and Numerical symbols on the body diagram to accurately identify the SPECIFIC DESCRIPTION, LOCATION and LEVEL of your Pain: Right Back Degree of Pain from: 1 (Discomfort) to 10 (Extreme Pain) Other Comments: D A 7 S A 8 Example N T 5 Back NAME (Print) SIGNATURE DATE [Pain Description Location Level]
HIPPA Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carryout treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. Protected health information is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health condition and related health care services. USES AND DISCLOSURES OF PROTECTED HEALH INFORMATION Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician s practice, and any other use required by law. Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission. Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician s practice. These activities include, but are not limited to, quality assessment, employee review, training of medical students, licensing, fundraising, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment, and inform you about treatment alternatives or other health-related benefits and services that may be of interest to you. We may use or disclose your protected health information in the following situations without your authorization. These situations include: as required by law, public health issues as required by law, communicable diseases, health oversight, abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, funeral directors, organ donation, research, criminal activity, military activity and national security, workers compensation, inmates, and other required uses and disclosures. Under the law, we must make disclosures to you upon your request. Under the law, we must also disclose your protected health information when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements under Section 164.500. Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization or opportunity to object unless required by law. You may revoke the authorization, at any time, in writing, except to the extent that your physician or the physician s practice has taken an action in reliance on the use or disclosure indicated in the authorization. [HIPPA Notice of Privacy Page 1]
YOUR RIGHTS The following are statements of your rights with respect to your protected health information. You have the right to inspect and copy your protected health information (fees may apply) Under federal law, however, you may not inspect or copy the following records: Psychotherapy notes, information compiled in reasonable anticipation of, or used in, a civil, criminal, or administrative action or proceeding, protected health information restricted by law, information that is related to medical research in which you have agreed to participate, information whose disclosure may result in harm or injury to you or to another person, or information that was obtained under a promise of confidentiality. You have the right to request a restriction of your protected health information This means you may ask us not to use or disclose any part of your protected health information and by law we must comply when the protected health information pertains solely to a health care item or service for which the health care provider involved has been paid out of pocket in full. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. By law, you may not request that we restrict the disclosure of your PHI for treatment purposes. You have the right to request to receive confidential communications You have the right to request confidential communication from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically. You have the right to request an amendment to your protected health information If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. You have the right to receive an accounting of certain disclosures You have the right to receive an accounting of all disclosures except for disclosures: pursuant to an authorization, for purposes of treatment, payment, healthcare operations; required by law, that occurred prior to April 14, 2003, or six years prior to the date of this request. You have the right to obtain a paper copy of this notice may from us even if you have agreed to receive the notice electronically. We reserve the right to change the terms of this notice and we will notify you of such changes on the following appointment. We will also make available copies of our new notice if you wish to obtain one. COMPLAINTS You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Compliance Officer of your complaint. We will not retaliate against you for filing a complaint. We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. We are also required to abide by the terms of the notice currently in effect. If you have any questions in reference to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number. Please sign the Acknowledgment of Receipt shown below. You are only acknowledging that you have received or been given the opportunity to receive a copy of our Notice of Privacy Practices. Print Name: Signature: Date: [HIPPA Notice of Privacy Page 2]
Assignment of Benefits PATIENT NAME: LAST FIRST MI MAIDEN OR OTHER NAME In consideration of services rendered or to be rendered, I hereby assign Thomas E. Dow D.C., P.C., my first party insurance benefits and rights, attendant thereto, as shall equal the full amount of the bill for said services and Thomas E. Dow D.C., P.C., may secure same in my name. I further understand if said sum is not collected, I will remain personally liable therefore. OR SIGNATURE OF PATIENT DATE PARENT / LEGAL GUARDIAN DATE WITNESS DATE [Assignment of Benefits]
Auto Accident or Injury Report Today s Date / / File Number Last Name First Name MI Auto Related Accident Date of Accident Time of Accident AM PM Were you the: Driver Front Passenger Rear Passenger Pedestrian If a traffic violation was issued, to whom was it issued? Me Other Person Number of people in accident vehicle you occupied? Did the police come to the accident site? Yes No Was a police report filed? Yes No Were there any witnesses? Yes No Were you wearing your seat belt? Yes No Was this vehicle equipped with airbags? Yes No If YES, did it/they inflate? Yes No In relation to the base of your skull, where was the headrest? Above Below At Base of Skull What did your vehicle impact? Another Vehicle Other If Other Please Describe: Did any part of your body strike anything in the vehicle? Yes No If Yes Please Describe: Who owned the vehicle you were in / struck by? Make and Model of vehicle you were occupying: Name of the Location / Street on which you were traveling? In which Direction were you headed? North South East West What was the approximate speed of your vehicle? Did the impact to your vehicle come from the: Front Rear Right Side Left Side Other During impact, were you facing: Right Left Forward Were you aware or surprised by the impact? Aware Surprised Did accident vehicle made impact with another vehicle? Another Object? If so, What? Direction other vehicle was headed? North South East West Approximate Speed of other vehicle? In your words, please describe the accident: After Injury Information Did the accident render you unconscious? Yes No If yes for how long? Please describe how you felt immediately after the accident: Have you gone to a hospital or seen any other doctor since the accident? Yes No When did you go? Just After Accident The Next Day 2 Days Plus Name of Hospital and/or Attending Doctor? Describe any treatment or tests you received: How did you get there: Ambulance Private Transportation Is He/She a: D.C. M.D. D.O. D.D.S. [Auto Accident Injury Report - Page 1]
Were X-Rays taken? Yes No Was Medication Prescribed? Yes No If Yes Describe: Have you been able to work since this injury? Yes No Give Dates you were unable to work: Are your work activities restricted as a result of this injury? Yes No Have you returned to work? Yes No Indicate the symptoms that are a result of this accident: Is your condition getting worse? Yes No Constant Comes & Goes Indicate your degree of comfort while performing the following activities: Laying on Back Laying on Side Lying on Stomach Sitting Standing Stretching Lovemaking Walking Running Sports Working Lifting Bending Kneeling Pulling Reaching Have you retained an attorney? Yes No If yes, whom: Phone Number: Recovery information To evaluate the effect that continuing work will have on your recovery please complete the following: How many hours are in your normal work day? Please indicate your daily job duties and any activities which you are occasionally asked to perform at work: What positions can you work in with minimum physical effort and for how long? Prior to the injury were you capable of working on an equal basis with others your age? Yes No N/A Do you work with others who can help you with any heavy lifting? Yes No N/A While in recovery is there any light duty work you could request? Yes No N/A N/A Signatures Insured s Name Patient s Signature Spouse or Guardian Signature Date Date If any of your medical or account information has changes, please inform our front desk personnel. Remember You are ultimately responsible for your account. Doctor s Notes [Auto Accident Injury Report - Page 2]
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS Motor Vehicle Accident Indemnification Corporation 110 WILLIAM STREET NEW YORK, N.Y. 10038 NAME AND ADDRESS OF APPLICANT
APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS [Page 2]
APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS [Page 3]
Thomas E. Dow, D.C., P.C. 535 Broadhollow Road, Suite A-10 Melville, New York 11747 ATTORNEY LIEN To Attorney: I do hereby authorize Thomas E. Dow, D.C., P.C. (TEDDCPC), to furnish you, my attorney/insurance carrier with a full report of my case history, examination, diagnosis, treatment and prognosis in regard to my accident which occurred on (Date). I hereby authorize and direct you, my attorney, to pay directly to TEDDCPC such sums as may be due owing TEDDCPC for professional services rendered to me both by reason of this accident, and by reason of any other bills that are do his office. Such sums owed TEDDCPC are to be withheld from my settlement/judgment, or verdict as may be necessary to protect said doctor. I hereby further authorize the funds be paid to TEDDCPC immediately upon receipt by you my attorney, and that such funds owed TEDDCPC are not to be held in escrow for any reason to delay payment to TEDDCPC. You as my attorney will also not engage in any negotiation with TEDDCPC to lower the fees owed, when my settlement is obtained by you. I understand that TEDDCPC must be paid first prior to any fees being released to me or you my attorney. I further understand that I am directly and fully responsible to TEDDCPC for all professional bills submitted by TEDDCPC for services rendered to me and that this agreement is made solely for TEDDCPC 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. Patient s Name: Patient s Signature: Date: The undersigned, being the attorney of record for the above patient, does hereby agree to observe all the terms of the above and agrees to withhold such sums from any settlement, judgment, or verdict as may be necessary to adequately protect TEDDCPC named above. Attorney s Name: Attorney s Signature: Date: Attorney: PLEASE DATE, SIGN AND RETURN ONE COPY TO TEDDCPC S OFFICE AT ONCE SO THAT WE MAY CONTINUE TREATING YOUR CLIENT.