corporateparkwellness.com - Personal Injury Form

Accident History Questionnaire
PERSONAL INJURY PATIENT HISTORY
Name
Date

MonthDayYear
Date
Date of Accident:

MonthDayYear
Date
Time(AM/PM):

Hour Minutes

AM/PM Option
Driver of Car:
Where were you seated?
Who owns the car?
Year & Model of your car.
Year & Model of other car.
What was the approximate damage done to your car?
$
Visibility at time of accident:

PoorFairGoodOther
Road conditions at time of accident:

IcyRainyWetClearDarkOther
Where was your car struck?

FrontRear
In your own words, please describe accident:
Type of Collision:

Head-onBroad-sideFront ImpactRear-end car in frontRear impactNon-collision
At the time of the accident, recall what parts of your head or body hit what parts on the inside of your car:

	Yes	No
Did you see the accident coming?
Did you brace for impact?
Were seatbelts worn?
Were shoulder harnesses worn?
Was your car braking?
Were you wearing a hat or glasses?

Does you car have headrests?

YesNo
If yes, what was the position of those headrests compared to your head before the accident?

Top of headrest even with bottom of headTop of headrest even with middle of neckTop of headrest even with top of head
Was your car moving at the time of the accident?

YesNo
If yes, how fast would you estimate you were going?(mph)
The other car?(mph)
Head/Body position at the time of impact:

Head turned left/rightHead looking backHead straight forwardBody straight in sitting positionBody rotated right/leftOther
As a result of the accident you were:

Rendered unconsciousIn shockDazed, circumstances vagueOther
How was the shoulder harness adjusted?

LooseSnug
Could you move all parts of your body?

YesNo
If no, what parts couldn't you move and why?
Were you able to get out of the car and walk unaided?

YesNo
If no, why not?
Did you get any bruises?

YesNo
If yes, where?
Did you get any bleeding cuts?

YesNo
If yes, where?
Describe how you felt immediately after the accident:
The next day:
Later that day:
Check symptoms apparent since the accident:

HeadacheChest painNeck pain/StiffnessMid back painLight sensitivityAnxious/NervousnessPain behind eyesDizzinessLow back painSleeping problemsNumbness in fingersLoss of smellNumbness in toesFaintingCold feetFacial PainLoss of memoryFatigueBreath shortnessLoss of tasteIrritabilityDepressionRinging/BuzzingCold SweatsLoss of balanceTensionConstipationCold handsClicking / Popping JawDiarrheaOther
Occupation:
Employer
Have you missed time from work:

YesNo
If yes, full time off work: to .
If yes, part time off work: to .
Did you seek medical help immediately after the accident?

YesNo
If yes, how did you get there?

AmbulancePoliceSomeone drove meDrove myselfOther
Doctor# 1: Name:
First Visit Date:

MonthDayYear
Date
Were you examined?

YesNo
Waft X-rays taken?

YesNo
Did you receive treatment?

YesNoMedicationsBracesCollars
If yes, what kind of treatment did you receive?
What benefits did you receive from the treatment?
Date of last treatment

MonthDayYear
Date
Doctor# 2: Name:
First Visit Date:

MonthDayYear
Date
Were you examined?

YesNo
Waft X-rays taken?

YesNo
Did you receive treatment?

YesNoMedicationsBracesCollars
If yes, what kind of treatment did you receive?
What benefits did you receive from the treatment?
Date of last treatment

MonthDayYear
Date
Do you have an attorney on this claim.?

YesNo
If yes, who
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Illustrate how the accident happened.

Patient name
File#
1. DOA:
2. PATIENT'S OWN AUTO INS INFO
Name of Ins Co:
Policy #
Claim #
Adjuster's name
Adjuster's phone
Please enter a valid phone number.
Med Pay status
Has accident been reported
3. 3RD PARTY INFO:
Name of third party
Third party auto Ins company
Claim #
Third party auto Ins claim adjuster
Third party auto Ins claim adjuster phone #
Please enter a valid phone number.
4. PROPERTY DAMAGE AMOUNT:
5. TYPE OF CAR OUR PATIENT WAS DRIVING:
Year
Make
Model
Damage was done to:
6. HEALTH INSURANCE INFO:
Name of health insurance co:
Name of insurance/policy holder:
SS# of insured/policy holder:
7. ATTORNEY
Attorney?

YesNo
Attorney Info:
Name:
Address:
Phone Number:
Please enter a valid phone number.

NOTICE OF DOCTOR'S LIEN
TO: Attorney
RE: Medical Reports and Doctor's Lien

I do hereby authorize the above doctor to furnish you, my attorney, with a full report of his/her examination, diagnosis, treatment, prognosis, etc., of myself in regard to the accident in which I was involved.

I hereby authorize and direct you, my attorney, to pay to said doctor such sums as may be due and owing him/her for medical service rendered me by reason of this accident and by reason of any other bills that are due his/her office and to withhold such sums from any settlement, judgment or verdict as may be necessary to adequately protect said doctor, And I hereby further give a lien on my case to said doctor against any and all proceeds of any settlement, judgment or verdict which may be paid to you, my attorney, or myself as the result of the injuries for which I have been treated or injuries in connection therewith.

I fully understand that I am directly and fully responsible to said doctor for all medical and/or surgical benefits, including major medical, submitted by him/her for service rendered me and that this agreement is made solely for said doctor's additional protection. I further understand that such payment is not contingent on any settlement, judgment or verdict by which I may eventually recover said fee. If this account is assigned for collection and/or suit, collection costs and/or interest, and/or attorneys fees, and/or court costs will be added to the total amount due.
Date

MonthDayYear
Date
Dated:

MonthDayYear
Date
Patient's Signature:

Clear
Witness:
Address:
ACKNOWLEDGEMENT OF ATTORNEY

The undersigned being 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 said doctor above named. Any settlement of this claim without honoring this assignment/lien will cause you to be responsible to this office for payment. The prevailing party in any litigation resulting from enforcement of this lien shall be entitled to actual attorney's fees and court costs.
Dated:

MonthDayYear
Date
Attorney's Signature:

Clear
Attorney: Please date, sign and return one copy to above doctor's office at once.
Reply envelope attached.
Keep one copy for your records. (Updated)

ASSIGNMENT OF BENEFITS
TO: (Insurance Co.)
Telephone No.
Please enter a valid phone number.
Date:

MonthDayYear
Date
You are instructed to pay directly to the below named doctor at his/her office for all professional services rendered to me by his/her office.

This instruction to you is an assignment of my rights under medical coverage to the extent of this bill.

Any sum of money paid under this assignment shall be credited to my account and I shall be personally liable for any unpaid balance to the doctor. Also, I am personally liable for any unpaid accounts for hospital, diagnostic and consultant services.
Patient's Signature:

Clear
Address:
Witness:
Policy Number:
ACKNOWLEDGMENT OF INSURANCE COMPANY

This insurance company hereby acknowledges receipt of the above instruction and agrees to mail payment of medical coverage benefits of the policy directly to the office of and to the order of the doctor only.
Date:

MonthDayYear
Date
Authorized Signature:

Clear
NOTE: If this acknowledgment is not signed and returned to the office of the doctor within seven (7) days, and if the patient continues under treatment after seven (7) days, it will be assumed and relied upon that the company has agreed to and acknowledges medical coverage and payment directly to the doctor.

Keep this copy attached to patient's chart. Do not send out bill or medical report until insurance company sends back signed copy. Call company in seven (7) days if no response.

3RD PARTY MEDICAL LIEN
Patient:
Claim #:
Date of Injury:

MonthDayYear
Date
I hereby authorize and direct The Type a label Insurance Company, to have the name of Type a label , D.C. placed along with mine on any settlement checked received for above mentioned loss.

I fully understand that I am directly and fully responsible to said doctor for all medical bills submitted by him for services rendered me and that this agreement is made solely for said doctor's protection and in consideration of awaiting payment.

Please acknowledge your agreement to this request by signing below and returning to doctor's office below. I have been advised that if you do not wish to cooperate in protecting the doctor's interest, the doctor will not await payment but the balance due and payable by me.
Date:

MonthDayYear
Date
Patient's Signature:

Clear
The undersigned insurance company does hereby agree to observe all the terms of the above.
Date

MonthDayYear
Date
Signature of Insurance Co. Representative

Clear
Name

First NameLast Name
Insurance Company Name

FINANCIAL AGREEMENT PERSONAL INJURY
We would like take a moment to welcome you to our office and to assure you that you will receive the very best care available for your injury. In order to familiarize with the financial policies of this office. I would like to explain how your medical bills will be handled.

Party Responsibility
If you were involved in an auto accident and are the owner of the vehicle. We will bill the medical insurance portion of your own automobile insurance policy. If you were a passenger in someone else's ear. We will bill the driver's auto insurance company. (These policies will be billed in addition, and prior to, any claim that your attorney may be presenting to an insurance company on your behalf.)

If you were a passenger in a vehicle which was not insured but you own a car which has medical coverage, the insurance company which carries YOUR policy will be responsible to pay your medical bills.

Insurance Rates
It is important to remember that when a medical claim is submitted to the "medical payments" portion of your insurance policy. Your standing with the insurance company will not be affected, and your rates will not normally be increased, unless the accident is determined to be your fault.

Billing Other Insurance Policies
It is also to your advantage for our office to bill your own health insurance policy and/or automobile medical policy for your medical bills, providing your policy doesn't state otherwise. Any money received above and beyond your total bill in this office will be refunded to you.

Responsibility for Payment
As a courtesy you, we will gladly submit your medical bills to your insurance company(ies) and/or your attorney; however, all services rendered by this office will be charged directly to you, and, ultimately, you will be personally responsible for payment of these bills regardless of any settlement you may or may not receive.

Once again, we welcome you in this office. We hope that this has answered any questions that you might have about our financial arrangements. If, at any time, you have further questions about your care, please don't hesitate to ask.

I have read and agree to the above.
Patient's Signature:

Clear
Date:

MonthDayYear
Date
Should be Empty:

Accident History Questionnaire

PERSONAL INJURY PATIENT HISTORY

PAST MEDICAL HISTORY:

FAMILY HISTORY:

PERSONAL HISTORY:

SYSTEM REVIEW

ACTIVITIES OF DAILY LIVING ASSESSMENT

CURRENT CHIEF COMPLAINTS:

SUBJECTIVE PAIN LEVEL:

Neck Pain and Disability Index (Vernon-Mior)

Low Back Pain and Disability Questionnaire (Revised Oswestry)

2. PATIENT'S OWN AUTO INS INFO

3. 3RD PARTY INFO:

5. TYPE OF CAR OUR PATIENT WAS DRIVING:

6. HEALTH INSURANCE INFO:

7. ATTORNEY

NOTICE OF DOCTOR'S LIEN

ASSIGNMENT OF BENEFITS

3RD PARTY MEDICAL LIEN

FINANCIAL AGREEMENT PERSONAL INJURY