New Patient Intake - Personal Injury

Personal Injury Patient Intake Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Your Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number*
What is your current Height?*
What is your current Weight? (in ilbs)*
RightLeft
Please list your current medications/any medications taken in the last year (Medication name & dosage if you remember it)*
Please list your previous health history - i.e. do you currently have or have you ever been diagnosed with any health conditions? Have you had any prior injuries or accidents other than the one you are being treated for today?*
Date of the Accident*

MonthDayYear
Date
What is the name of your Attorney?*
For your Auto or Personal Injury Claim, please enter your Insurance Carrier (You may put N/A if you have not filed the claim yet)*
For your Auto or Personal Injury Claim, please enter your Claim Number (You may put N/A if you have not filed the claim yet)*
Please upload a copy/photo of the FRONT of your HEALTH INSURANCE Card. Why do we ask for this? We may need to submit for denials with your health insurance carrier in order to get your claims properly paid. *You will not be treated under personal health insurance, this is purely for compliance purposes. *

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Please upload a copy/photo of the BACK of your HEALTH INSURANCE Card. Why do we ask for this? We may need to submit for denials with your health insurance carrier in order to get your claims properly paid. *You will not be treated under personal health insurance, this is purely for compliance purposes. *

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If you do not have any personal health insurance plan, please note so here.
Please describe the nature of your injury and how it occurred, including the location if you know it.*
Please describe your treatment course since the accident. For example, were you taken to the hospital right after, did you have therapy, were any x-rays/MRIs done, did you undergo injections or surgeries?*
Which areas of the body are injured as a result of this?*
Please describe the current pain you are feeling in these area*
What type of work were you doing at the time of the injury? Did you miss any work as a result of the injury? What work are you currently doing/involved in?*
Do you have to make any accommodations at work as result of the injury?*
Please list any activities that are limited as a result of the injury, specifically, were there things you enjoyed doing in the past that you can no longer do as a result of the injury?*
PRIOR to this injury, have you had any other injuries, including slip and falls, car accidents, work injuries etc.?*
SINCE this injury, have you had any new injuries including slip and falls, car accidents, work injuries, etc.?

Assignment of Benefits
ASSIGNMENT OF BENEFITS & AUTHORIZATION FOR DIRECT PAYMENT

I hereby assign all applicable medical and/or insurance benefits to CarePath Injury Centers for services rendered in connection with my Workers’ Compensation (WC) / Motor Vehicle Accident (MVA) claim. I authorize direct payment to CarePath Injury Centers from my insurance carrier or any responsible third party payer.

I understand that this assignment of benefits does not relieve me of financial responsibility for any charges not covered by my insurance, including but not limited to co-payments, deductibles, denied claims, or limitations on coverage. I agree to cooperate with CarePath Injury Centers & my legal teams in any necessary efforts to secure payment, including but not limited to providing additional information, signing required documents, or pursuing appeals for denied claims.

Release of Information:
I authorize CarePath Injury Centers to release any medical records, reports, or other necessary information to my insurance carrier, legal representatives, and other involved parties for the purpose of claim processing, billing, and reimbursement.

Lien & Third-Party Reimbursement Agreement (if applicable):
I understand that if my claim is subject to litigation or settlement, I authorize my attorney to make payment directly to CarePath Injury Centers for any outstanding medical bills from settlement proceeds. I agree to inform CarePath Injury Centers of any changes regarding my legal representation, insurance coverage, or claim status.

Acknowledgment & Signature:
By signing below, I confirm that I have read and understood this Assignment of Benefits
Patient Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
Signature*

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Records Release
I hearby give CarePath Injury Centers of Pennsylvania permission to request and receive medical, imaging, and other associated records from other institutions that I have visited, been seen or been a patient at for my accident/injury. They may request records on my behalf and receive them to utilize for my care plan with them moving forward.
Today's Date*

MonthDayYear
Date
Patient's Name*

First NameLast Name
Patient's Signature*

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Privacy & HIPAA Release
CAREPATH INJURY CENTERS
NOTICE OF PRIVACY PRACTICES & AUTHORIZATION
How We May Use and Disclose Your Health Information
CarePath Injury Centers is required by law to protect the privacy of your Protected Health Information (PHI). This notice explains how we may use and disclose your medical information.

We may use and disclose your PHI for:

Treatment – To provide, coordinate, or manage your healthcare.
Payment – To bill and collect payment for services rendered.
Healthcare Operations – For administrative, quality assurance, licensing, compliance, and business management purposes.
Medical-Legal Case Management – To communicate with your attorney of record, insurance carriers, third-party administrators, case managers, employers (where applicable), and other parties involved in your personal injury or workers’ compensation claim.

We may also disclose your PHI when required by law, including but not limited to court orders, subpoenas, workers’ compensation reporting requirements, public health reporting, or regulatory compliance.

Your information may be shared electronically, verbally, or in written form as permitted by law.

Your Rights
You have the right to:

Request access to your medical records
Request corrections to your records
Request restrictions on certain disclosures (though we are not required to agree)
Request confidential communications
Receive a copy of this notice
File a complaint if you believe your privacy rights have been violated
Complaints may be directed to CarePath Injury Centers’ Privacy Officer.
HIPAA Acknowledgment & Authorization for Release of Information

Acknowledgment of Receipt of Notice of Privacy Practices
I acknowledge that I have received or have been made available CarePath Injury Centers’ Notice of Privacy Practices. I understand this notice explains how my Protected Health Information (PHI) may be used and disclosed for treatment, payment, healthcare operations, and medical-legal case management.

I understand that I may request a copy of the Notice of Privacy Practices at any time.

Authorization to Disclose Protected Health Information

I authorize CarePath Injury Centers to disclose my Protected Health Information (PHI) to the individual(s) listed below INCLUDING my listed Attorney (above in the form). This may include appointment information, treatment status, billing information, medical records, and case-related updates as authorized.

Scope of Authorization
I authorize full disclosure of my medical and billing information.
I authorize limited disclosure as follows:
Name of Individual*
Relationship to Patient*
Individual's Phone Number*
Attorney Name*
Attorney Law Firm/Practice Name*
Patient (Your) Full Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
Signature*

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Personal Injury Patient Intake Form

Assignment of Benefits

Records Release

Privacy & HIPAA Release