1. PIP Paperwork

PI Accident / Work Comp
Date:

MesDíaAño
2 digit month, 2 digit day, 4 digit yearFecha
Name:

First NameLast Name
Date of birth:

MesDíaAño
2 digit month, 2 digit day, 4 digit yearFecha
Age:
Gender:
Marital Status:
E mail:
ejemplo@ejemplo.com
Mobile:
Address:

Address

Street Address Line 2

CityState

Zip
Employer:
Occupation:
Emergency contact:
Name and Phone Number
Relationship:
Please answer all the questions complety.

Dear patient: This information is considered confidential. We need this information because we care enough to want to know and your answers will help us determine if chiropractic care can help you. If we do not sincerely believe your condition will respond satisfactorily, we will not accept your case. In order for us to understand your condition properly, please be as neat and accurate as possible while completing this form. Thank you.
Please explain in detail how your accident hapenned:
You were heading    *      on (road, street, highway)* . Other vehicle was heading    *       on   (road, street, highway)   *   .
Were you knocked unconscious?   *  . If so, for how long .
You were struck from *      . You were    * .
Date of accident:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Time of accident:
Where did you feel pain immediately:
List the extend of your injuries as you know them:
What relieves the symptoms?
What makes them feel worse?
List any restricted activities:
Note: To do in clinic. Please mark the areas on the diagram with the following letters to describe your symptoms:

R= Radiating B=Burning D=Dull A=Aching N=Numbness S=Sharp T=Tingling

Patient Name:
Date:

MesDíaAño
2 digit month, 2 digit day, 4 digit yearFecha
Instructions: Please read carefully.

Where do you feel pain? Please answer questions for each area of complaint.
Note: 0 is equal to no pain and 10 is equal to worst possible pain.
a)
What is your pain right now?
What is your average pain?
What is your pain at its best?
What is your pain at its worse?
b)
What is your pain right now?
What is your average pain?
What is your pain at its best?
What is your pain at its worse?
c)
What is your pain right now?
What is your average pain?
What is your pain at its best?
What is your pain at its worse?
Other comments:

Patient Name:
Date:

MesDíaAño
2 digit month, 2 digit day, 4 digit yearFecha
Date of collision:

MesDíaAño
2 digit month, 2 digit day, 4 digit yearFecha
Instructions: Please fill out the following
Body Position
Your vehicle type:
Who hit whom?:
Road condition:
How were you hit?:
Visibility:
Head position:
Location:
Work or school:
Work or school:
Did you see the car?:
You were:
Seat belt?:
Braced?:
Shoulder strap?:
Air bag deployed?:
Your body hit:
Did you...:
Vehicle damage:
After, you went?:
After, you felt?:
Later days, you felt?:
Did you noticed?:
Treatment:
Your vehicle speed:
Their vehicle speed:
Time of accident:

AM/PM Option

Insurance Verification
Patient Name:
Date of accident:

MesDíaAño
2 digit month, 2 digit day, 4 digit year
Who was at fault?
Your Insurance Info:
Insurance company:
Claim number:
Policy number:
Claim e mail address:
ejemplo@ejemplo.com
Claim physical address:
Agent Phone Number:
MedPay:
Other Party Insurance Info:
Name of person at fault:
Insurance company:
Claim number:
Policy number:
Claim physical address:
Agent Phone Number:
Claim e mail address:
Lawyer:
Name:
Phone number:
Address:
E mail address:

INFORMED CONSENT
REGARDING: Chiropractic Adjustments, Modalities, and Therapeutic Procedures.

I have been advised that chiropractic care, like all forms of health care, holds certain risks. While the risk are most often very minimal, in rare cases, complications such as sprain/strain injuries, irritation of a disc condition, and although rare, minor fractures, and possible stroke, which occurs at a rate between one instance per one million to one per two million, have been associated with chiropractic adjustments.

Treatment objectives as well as the risks associated with chiropractic adjustments and, all other procedures provided at Innovative Chiropractic have been explained to me to my satisfaction and I have conveyed my understanding of both to the doctor. After careful consideration, I do hereby consent to treatment by any means, method, and or techniques, the doctor deems necessary to treat my condition at any time throughout the entire clinical course of my care.

I hereby authorize payment to be made directly to Innovative Chiropractic, for all benefits which may be payable under a healthcare plan or from any other collateral sources. I authorize utilization of this application or copies for the purpose of processing claims and effecting payments, and further acknowledge that this assignment of benefits does not in any way relieve me of payment liability and that I will remain financially responsible to Innovative Chiropractic for any and all services I receive at this office.
Date

MesDíaAño
2 digit month, 2 digit day, 4 digit year
Patient or Authorized Person's Signature
FEMALES ONLY
REGARDING: X-rays/Imaging Studies.
Please read carefully and check the boxes, include the appropriate date, then sign below if you understand and have no further questions, otherwise see our receptionist for further explanation.

Date I have been provided a full explanation of when I am most likely to become pregnant, and to the best of my knowledge, I am not pregnant.

By my signature below I am acknowledging that the doctor and or a member of the staff has discussed with me the hazardous effects of ionization to an unborn child, and I have conveyed my understanding of the risks associated with exposure to x-rays. After careful consideration I therefore, do hereby consent to have the diagnostic x-ray examination the doctor has deemed necessary in my case.
The first day of my last menstrual cycle was on:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient or Authorized person's Signature:
Date:

MesDíaAño
2 digit month, 2 digit day, 4 digit year

INNOVATIVE CHIROPRACTIC NOTICE OF PRIVACY PRACTICE
This office is required to notify you in writing, that by law, we must maintain the privacy and confidentiality of your Personal Health Information. In addition we must provide you with written notice concerning your rights to gain access to your health information, and the potential circumstances under which, by law, or as dictated by our office policy, we are permitted to disclose information about you to a third party without your authorization. Below is a brief summary of these circumstances. Once you have read this notice, please sign the last page, and return only the signature page (page 2) to our front desk receptionist. Keep this page for your records.
- Treatment purposes- discussion with other health care providers involved in your care
- Inadvertent disclosures- open treating area mean open discussion. If you need to speak privately to the doctor, please let our staff know so we can place you in a private consultation room.
- For payment purposes - to obtain payment from your insurance company or any other collateral source.
- For workers compensation purposes- to process a claim or aid in investigation
- Emergency- in the event of a medical emergency we may notify a family member
- For Public health and safety - in order to prevent or lessen a serious or eminent threat to the health or safety of a person or general public.
- To Government agencies or Law enforcement – to identify or locate a suspect, fugitive, material witness or missing person.
- For military, national security, prisoner and government benefits purposes.
- Deceased persons –discussion with coroners and medical examiners in the event of a patient’s death.
- Telephone calls or emails and appointment reminders -we may call your home and leave messages regarding a missed appointment or apprize you of changes in practice hours or up-coming events.
- Change of ownership- in the event this practice is sold, the new owners would have access to your
- To receive an accounting of disclosures
- To receive a paper copy of the comprehensive “Detail” Privacy Notice
- To request mailings to an address different than residence
- To request Restrictions on certain uses and disclosures and with whom we release information to, although we are not required to comply. If, however, we agree, the restriction will be in place until written notice of your intent to remove the restriction.
- To inspect your records and receive one copy of your records at no charge, with notice in advance
- To request amendments to information. However, like restrictions, we are not required to agree to them.
- To obtain one copy of your records at no charge, when timely notice is provided (72 hours X-rays are original records and you are therefore not entitled to them. If you would like us to outsource them to an imaging center, to have copies made, we will be happy to accommodate you. However, you will be responsible for this cost. COMPLAINTS: If you wish to make a formal complaint about how we handle your health information, please call at (720) 439-7890. If she is unavailable, you may leave a message and she will call you back to schedule an appointment within 72 hours or 3 working days. If you are still not satisfied with the manner in which this office handles your complaint, you can submit a formal complaint to:
DHHS, Office of Civil Rights 200 Independence Ave. SW Room 509F HHH Building Washington DC 20201
Initials:
I have received a copy of Innovative Chiropractic’s Patient Privacy Notice. I understand my rights as well as the practices duty to protect my health information, and have conveyed my understanding of these rights and duties to the doctor. I further understand that this office reserves the right to amend this ‘Notice of Privacy Practice” at any time in the future and will make the new provisions effective for all information that it maintains past and present.

I am aware that a more comprehensive version of this “Notice” is available to me and several copies kept in the reception area. At this time, I do not have any questions regarding my rights or any of the information I have received.
Patient's Name:
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Patient signature:
Date:

MesDíaAño
2 digit month, 2 digit day, 4 digit yearFecha

COLORADO HEALTH-CARE PROVIDER LIEN

REQUIRED DISCLOSURES, ADVISEMENTS, AND LIMITATIONSPursuant to C.R.S. §§ 38-27.5-101 through 38-27.5-108
Name

First NameLast Name
Date of Accident

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Attorney (if applicable):
Provider name: Dr. Randy Gilkay D.C.
Clinic: Innovative Chiropractic
Address: 5800 E. Evans Ave. Denver, CO 80222

IMPORTANT NOTICE TO PATIENT

You are receiving health-care services under a health-care provider lien. A health-care provider lien is related to charges for health-care services provided to a person injured as a result of another person's negligence or wrongful acts and is asserted against money received from a claim against a third party or under an uninsured or underinsured motorist insurance policy.

Before this lien is created, Colorado law requires that you receive the following disclosures and advisements.

1. OPTIONS FOR PAYMENT OF YOUR HEALTH-CARE CHARGES

Potential methods for payment of the health-care provider's billed charges include:

A. Creation of a health-care provider lien;

B. Use of benefits available from any payer of benefits, as defined by Colorado law, to which you are a beneficiary. You may obtain information concerning the payer's provider network from the payer of benefits or the health-care provider;

C. Any other payment method or arrangement agreed to in writing by you and the health-care provider or its assignee; or

D. A combination of the payment methods described above.

2. PROVIDER IS NOT AN INSURER

You are advised that the health-care provider, and any assignee of the health-care provider lien, is not a health insurer or payer of benefits and does not pay or reimburse health-care expenses or services.

3. IMPORTANT LIMITATIONS ON YOUR PERSONAL LIABILITY

Except in the event of fraud or misrepresentation by the injured person:

A. No Recovery. If you do not receive a judgment, settlement, or payment on your claim against a third party or under an uninsured or underinsured motorist insurance policy, you are not liable to the holder of the health-care provider lien for any portion of the lien.

B. Recovery Less Than the Lien. If your net judgment, settlement, or payment is less than the full amount of the health-care provider lien, you are not liable for any amount of the lien beyond your net judgment, settlement, or payment. For purposes of Colorado's health-care provider lien law, a "net judgment, settlement, or payment" generally means the proceeds received on the applicable claim after reasonable attorney fees and litigation expenses, if any.

C. No Direct Action for the Excess. The lienholder may not file a complaint or counterclaim directly against you to obtain reimbursement for an amount beyond your net judgment, settlement, or payment.

Nothing in this provision prevents a health-care provider or assignee from initiating a declaratory judgment action, participating in an interpleader action or claim under the Colorado Rules of Civil Procedure, or participating in another similar action or claim to determine the provider's or assignee's share of the net judgment, settlement, or payment.

D. No Collection-Agency Assignment. The health-care provider or its assignee may not assign the health-care provider lien to a collection agency or debt collector.

These limitations appear both in the mandatory disclosures under §104 and the substantive limitations under §105.

4. LIMIT ON THE AMOUNT OF THE LIEN

The amount of the health-care provider lien must not exceed the charges for services actually provided to you at the time of service at a rate equal to the provider's usual and customary billed charge. Colorado law defines a "usual and customary billed charge" as a provider's billed charge in the absence of insurance for a service that is similar to billed charges for like services provided by other health-care providers in the same geographic area. The provider or its assignee will not add a finance charge or otherwise increase the provider's usual and customary billed charge when creating or claiming this health-care provider lien. You are obligated under the lien only for the amount permitted by Colorado's health-care provider lien law.

5. COMMON OWNERSHIP DISCLOSURES

Common ownership between the holder of this lien and your legal counsel:

☐ None
☐ Yes — Description: ______________________________________________

Common ownership between an assignee of this lien and a health-care provider providing or potentially providing treatment under this lien:

☐ None / Not applicable
☐ Yes — Description: ______________________________________________

6. FUTURE HEALTH INSURANCE

If you obtain health insurance after this health-care provider lien has been created and you or your legal counsel informs the lienholder, all future care may be billed to your health insurance carrier at your discretion.

Any unpaid amount that remains subject to a valid health-care provider lien will continue to be asserted against the applicable judgment, settlement, or payment arising from the injury or incident, subject to all limitations and protections provided by C.R.S. Article 27.5 of Title 38.

7. COLORADO MEDICAL ASSISTANCE

Nothing in this agreement changes any obligation of the health-care provider or its agents under the Colorado Medical Assistance Act, Articles 4 through 6 of Title 25.5, C.R.S.

8. ITEMIZED STATEMENTS
Upon request by you or your legal counsel, the holder of the health-care provider lien will provide you in writing with an itemized statement of billed charges comprising the value of the lien as those charges accrue, to the extent practicable.

When the lien is final, the final itemized statement will include:

A summary of all treatments provided;
The total amounts billed for each treatment; and
The total amount of the health-care provider lien due and owing.

9. ACKNOWLEDGMENT AND CREATION OF HEALTH-CARE PROVIDER LIEN

I acknowledge that I received and reviewed the disclosures and advisements above before creation of this health-care provider lien. I understand the payment options described above and voluntarily elect to receive applicable health-care services on a health-care provider lien basis. To the extent permitted by Colorado law, I grant the health-care provider a lien against money I receive from my applicable claim or claims against third parties or under an uninsured or underinsured motorist insurance policy for the accident or incident identified above. I understand that this lien is subject to all limitations and protections provided by C.R.S. Article 27.5 of Title 38, including the limitations described in this agreement. I acknowledge that I have had an opportunity to ask questions regarding this agreement before signing it.

10. DIRECT PAYMENT TO PATIENT

If an insurance company, payer of benefits, third-party liability carrier, uninsured/underinsured motorist carrier, or other responsible payer issues payment directly to me that is specifically attributable to or intended as payment or reimbursement for health-care services provided by the Health-Care Provider, I agree to notify the Health-Care Provider promptly and remit to the Health-Care Provider the applicable amount received for those services.

I agree not to knowingly spend, transfer, conceal, or otherwise dispose of funds specifically identified as payment or reimbursement for the Health-Care Provider's services before satisfying the amount lawfully payable to the Health-Care Provider.

Payment is due within seven (7) calendar days after my receipt of such funds.

Nothing in this provision increases my liability beyond the amount permitted under C.R.S. Article 27.5 of Title 38 or waives any protection provided to me by Colorado law.
Print Name:
Date:

MesDíaAño
2 digit month, 2 digit day, 4 digit yearFecha
Signature
Should be Empty:

PI Accident / Work Comp

Insurance Verification

Your Insurance Info:

Other Party Insurance Info:

Lawyer:

INFORMED CONSENT

FEMALES ONLY

INNOVATIVE CHIROPRACTIC NOTICE OF PRIVACY PRACTICE

COLORADO HEALTH-CARE PROVIDER LIEN