1. PIP Paperwork

PI Accident / Work Comp
Date:*

MesDíaAño
Fecha
Name:*

First NameLast Name
Date of birth:*

MesDíaAño
Fecha
Age:
Gender:*

MaleFemale
Marital Status:*

SingleMarried
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
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
Fecha
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
Fecha
Date of collision:*

MesDíaAño
Fecha
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
Who was at fault?*

YouOther party
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
Patient or Authorized Person's Signature*

Clear
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
Date
Patient or Authorized person's Signature:

Clear
Date:

MesDíaAño

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
Patient signature:*

Clear
Date:*

MesDíaAño
Fecha

ASSIGNMENT OF BENEFITS, ASSIGNMENT OF RIGHTS TO PURSUE PERSONAL INJURY, WORK COMP, ERISA, AND OTHER LEGAL AND ADMINISTRATIVE CLAIMS ASSOCIATED WITH MY HEALTH INSURANCE AND /OR HEALTH BENEFIT PLAN (INCLUDING BREACH OF FIDUCIARY DUTY) AND DESIGNATION OF AUTHORIZED REPRESENTATIVE
Provider name: Dr. Randy Gilkay D.C.
Clinic: Innovative Chiropractic
Address: 5800 E. Evans Ave. Denver, CO 80222

I hereby assign and convey directly to the above-named health provider, as my designated authorized representative, any and all medical benefits and /or insurance reimbursement, if any, otherwise payable to me for services, treatments, therapies, and /or medications rendered or provided by the above-named health care provider, regardless of its managed care network participation status. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize the above-named health care provider to release all medical information necessary to process my claims. Further, I hereby authorize my plan administrator fiduciary, insurer, and /or attorney to release the above-named health care provider any and all Plan documents, summary benefit description, insurance policy, and /or settlement information upon written request from the above-named health care provider or its attorneys in order to claim such medical benefits.

In addition to the assignment of all medical benefits and /or insurance reimbursement above, I also assign and /or convey to the above-named health care provider any legal or administrative claim or chosen action arising under any group health plan, employee benefits plan, health insurance or tort feasor insurance concerning medical expenses incurred as a result of the medical services, treatments, therapies, and /or medications I receive from the above-named health care provider (including any right to pursue those legal or administrative claims or chosen action This constitutes an express and knowing assignment of ERISA breach or fiduciary duty claims and other legal and /or administrative claims.

I intend by this assignment and designation of authorized representative to convey to the above-named provider all of my rights to claim (or place a lien on) the medical benefits related to the services, treatments, therapies, and /or medications provided by the above-named health care provider, including rights to any settlement, insurance, or applicable legal or administrative remedies (including damages arising from ERISA breach of fiduciary duty claims The assignee and /or designated representative (above-named provider) is given the right by me to (1) obtain information regarding the claim to the same extent as me; (2) submit evidence; (3) make statements about facts or law; (4) make any request including providing or receiving notice of appeal proceedings; (5) participate in any administrative and judicial actions and pursue claims or chosen action or right against any liable party, insurance company, employee benefit plan, health care benefit plan, or plan administrator. The above-named provider as my assignee and designated authorized representative may bring suit against any such health care benefit plan, employee benefit plan, plan administrator or insurance company in my name with derivative standing at provider's expense.

Unless revoked, this assignment is valid for all administrative and judicial reviews under PPACA (health care reform legislation), ERISA, Medicare and applicable federal and state laws. A photocopy of this assignment is to be considered valid, the same as if it was the original.

I HAVE READ AND FULLY UNDERSTAND THIS AGREEMENT
Print Name:*
Date:*

MesDíaAño
Fecha
Signature*

Clear
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

ASSIGNMENT OF BENEFITS, ASSIGNMENT OF RIGHTS TO PURSUE PERSONAL INJURY, WORK COMP, ERISA, AND OTHER LEGAL AND ADMINISTRATIVE CLAIMS ASSOCIATED WITH MY HEALTH INSURANCE AND /OR HEALTH BENEFIT PLAN (INCLUDING BREACH OF FIDUCIARY DUTY) AND DESIGNATION OF AUTHORIZED REPRESENTATIVE