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
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 # Email 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 - 5331 NW Macadam Ave. Suite #307 - Portland, OR 97239 (503) 226-8010*
!"#$%&"'(%%$)"*+',*-./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?
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
Namasté Integrative Medicine Allen Knecht, D.C. 5331 SW Macadam Ave. Ste #307 Ben Narcisi, D.C. Portland, OR 97239 P(503) 226-8010 - F(503) 210-0338 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.
Namasté Integrative Medicine 5331 SW Macadam Ave. Suite #307 Portland, OR 97239 (503) 226-8010 - Fax: (503) 210-0338 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
Namasté Integrative Medicine 5331 SW Macadam Ave Suite #307 Portland, OR 97239 (503) 226-8010 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. 1. 4 2. 4 3. 4 4 4 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 : 5587-592
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
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:
Namasté Integrative Medicine 5331 SW Macadam Ave. Suite 307 Portland, OR 97239 P(503) 226-8010 - F(503) 210-0338 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
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