• Patient Basic Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
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  • Automobile Insurance Information

  • Format: (000) 000-0000.

  • If someone else was at fault

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Our Office will provide insurance billing services for you if you so desire as a courtesy. Remember that you are ultimately responsible for any
    charges incurred in this office. It is your responsibility to pay any deductible amount, co-insurance, and or any other balances not paid by your
    insurance carrier. Your signature on this document indicates that you agree to pay for any outstanding bills incurred in this office.

  • Description of Accident / Injury / Onset

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  • During and after accident details

  • Automobile Accident Description

  • Please answer the questions below. If you do not know the answer to any question, leave it blank.

  • Time / Speed / Damage

  • Details of Accident

  • Road Conditions

  • Rows

  • During the Accident

  • After the Accident

  • Emergency Room

  • Treatment History

    Fill in other doctor(s) seen prior to your first visit to this office.
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  • Description of Symptoms

    Describe your symptoms in the sections below, in the order of severity, if possible.

  • I. Current Symptom: (Please check off the boxes below to describe your symptom. Describe only ONE symptom per section.)

  • Rows
  • Rows
  • Rows

  • II. Current Symptom: (Please check off the boxes below to describe your symptom. Describe only ONE symptom per section.)

  • Rows
  • Rows
  • Rows

  • III. Current Symptom: (Please check off the boxes below to describe your symptom. Describe only ONE symptom per section.)

  • Rows
  • Rows
  • Rows

  • IV. Current Symptom: (Please check off the boxes below to describe your symptom. Describe only ONE symptom per section.)

  • Rows
  • Rows
  • Rows

  • V. Current Symptom: (Please check off the boxes below to describe your symptom. Describe only ONE symptom per section.)

  • Rows
  • Rows
  • Rows

  • VI. Current Symptom: (Please check off the boxes below to describe your symptom. Describe only ONE symptom per section.)

  • Rows
  • Rows
  • Rows

  • Activities of Daily Living Assessment

  • Rate your current difficulties, resulting from your accident/illness, with regard to the various activities listed below. Use the following 1 to 5 scale and WRITE IN THE APPROPRIATE NUMBER that most closely describes your current degree of difficulty.

    1 = "I can do it without any difficulty", 2 = "I can do it without much difficulty, despite some pain", 3 = "I manage to do it by myself, despite marked pain", 4 = "I manage to do it, despite the pain, but only if I have help", 5 = "I cannot do it all, because of the pain". 

  • Difficulties with Self Care and Personal Hygiene Activities

  • Difficulties with Physical Activities

  • Difficulties with Functional Activities

  • Difficulties with Social and Recreational Activities

  • Difficulties with Travelling

  • Use the following 1 to 5 scale to describe the difficulties below:

    1 = "This area is not affected by my condition", 2 = "This area is slightly affected by my condition", 3 = "My condition moderately restricts my ability in this area", 4 = " My condition seriously limits my ability in this area", 5 = "My condition prevents me from using this ability"

  • Difficulties with Different Forms of Communication

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  • Difficulties with the Senses

  • Difficulties with Hand Functions

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  • Difficulties with Sleep and Sexual Function

  • Prior Symptom History

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  • It is essential that if your insurance carrier sends you forms that need to be signed for authorization of records, you sign these documents and return them to the carrier as soon as possible.

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  • Neck Index

    This questionnaire will give your provider information about how your neck condition affects your everyday life. Please answer every section by marking the one statement that applies to you. If two or more statements in one section apply, please select the one statement that most closely describes your problem.
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  • Back Index

    This questionnaire will give your provider information about how your back condition affects your everyday life. Please answer every section by marking the one statement that applies to you. If two or more statements in one section apply, please select the one statement that most closely describes your problem.
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  • HIPAA Notice of Privacy Practices Acknowledgement

  • I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

    • Conduct, plan, and direct my treatment and follow-up among multiple healthcare providers involved in my care.
    • Obtain payment from third-party payers.
    • Conduct normal healthcare operations such as quality assessments and professional certifications.

    I have received, read, and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this office has the right to change its Notice of Privacy Practices from time to time as necessitated by changes in HIPAA.

    I understand that I may request, in writing, that you restrict how my private information is used or disclosed to carry out treatment, payment, or healthcare operations.

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  • OFFICE USE ONLY

  • I attempted to obtain the patient's signature in acknowledgement of receipt of the HIPAA Notice of Privacy Practices Acknowledgement, but was unable to do so as documented below.

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  • Radiograph Authorization

  • I,      , authorize my Chiropractic Physician to take radiographic imaging on me when necessary. I am not pregnant and I am not wearing any mechanic devices which can be damaged by radiation.

    Unless I was offered free X-ray, I understand that I will be responsible for the fee. However, I will not be responsible for X-ray service charges when my insurance covers the fee.

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  • Contractual Guarantee of Payment

  • I, , hereby grant to Unison Chiropractic this Contractual Guarantee of Payment against my personal injury case for the accident dated Pick a Datefor medical services.

    I hereby authorize and direct my attorney/insurance company to pay directly to Unison Chiropractic such sums as may be due and owing to Unison Chiropractic for medical services rendered to me for the above dated accident by Unison Chiropractic. I further direct my attorney to withhold such sums from any settlement or judgment obtained as a result of my personal injury, necessary to adequately protect Unison Chiropractic interests, regardless of the amount of settlement.

    I agree that this contract is non-revocable. I understand that once this contract is presented to my attorney, he/she will not honor any attempt by me to rescind this agreement. If another attorney is substituted in this manner, I agree that Unison Chiropractic may file this contract with my new attorney, and I direct the attorney to honor this contract.

    I understand that I am directly and fully responsible to Unison Chiropractic for all services rendered by Unison Chiropract

    DATED this:      day of      , 20

  • The undersigned attorney of record for the above patient agrees to honor Unison Chiropractic’s Contractual Guarantee of Payment and further agrees to withhold such sums from any settlement of judgment sufficient to adequately protect Unison Chiropractic.

    DATED this:      day of      , 20

  • DISCLOSURE REGARDING USE OF MEDICAL LIENS

  • I understand that for treatment provided by Unison Chiropractic related to an automobile collision, primary first party insurance is with the Personal Injury Protection (PIP) Insurance for the car I was driving, riding in as a passenger, or struck by as a pedestrian/bicyclist. I understand and authorize Unison Chiropractic to bill PIP and authorize the release of any information acquired in the course of my examination and treatment in accordance with HIPAA privacy regulations.

    Should PIP insurance not be available, exhaust or terminate for any reason, I authorize Unison Chiropractic to bill any applicable health insurance I may have available, subject to any contract Unison Chiropractic may have with such carrier. I understand and authorize Unison Chiropractic to bill health insurance, if applicable, and authorize the release of any information acquired in the course of my examination and treatment in accordance with HIPAA privacy regulations.

    I authorize Unison Chiropractic to file a medical lien against any applicable third-party insurance settlement pursuant to RCW 60.44.010, et seq. I understand I may then be asked to make minimum monthly payments on any balance owed. I understand and acknowledge that in the event a medical lien is filed, and that if the lien is paid or settled, I will be provided with an original, written Satisfaction of Lien and I am responsible for filing the Satisfaction of Lien with the County Auditor and for paying the filing fee costs associated with filing any such Satisfaction of Lien. I further understand that payment of any medical lien, in some circumstances, may not fully pay my outstanding final charges due to Unison Chiropractic for treatment provided, and I may be required to make additional payments after satisfaction of the lien.

  • DATED this:      day of      , 20,at   Washington.

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  • PATIENT INSTRUCTION AND AUTHORIZATION TO PERSONAL INJURY INSURANCE CARRIER TO MAKE DIRECT PAYMENT TO CHIROPRACTOR

  • I hereby authorize and instruct the following Insurance Company      
    to send (mail) all paid monies for diagnostic testing, treatment and/or medical supplies to Dr. Tae M. Ahn d.b.a. Unison Chiropractic.

  • Please read and initial each statement stated below:  


       I authorize said Doctor to release any information pertinent to my case to the above mentioned insurance carrier.

      A photocopy of this authorization shall be considered as valid as the original and good through the duration of my claim.

      I authorize said Doctor to use my name in the “Signature on File” in future billings.

      I authorize direct payment to said Doctor.

      I authorize use of this form on all my insurance submissions.

      I authorize the above mentioned insurance carrier to release any information pertinent to my case to said Doctor through the duration of my claim.


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  • WAIVER OF INTEREST CHARGE AGREEMENT

  • Unison Chiropractic charges 1% monthly compound interest on all personal injury accounts in which we have agreed to waive receipt of payment until the case reaches settlement, and/or PIP benefits have been exhausted.

    We have, however, devised a program so that you may avoid having these interest charges accrue on your account. This program is outlined below.

    • The patient acknowledges that Unison Chiropractic is currently charging this 1% monthly compound interest on all balances 30 days or more past due.
    • The patient agrees to make minimum payments of $50.00 each and every month to Unison Chiropractic towards all balances owing in relation to the patient’s personal injury.
    • The $50.00 monthly payments must be received by the FIRST of each month, with a grace period extending until the fifth of that month.
    • If payment is not received within the specified period of time, we will charge 1% interest of that month on the entire balance of that account.
    • The patient can choose to discontinue this agreement at any time with 15 days’ notice given to Unison Chiropractic.
    • Upon discontinuation of payment, Unison Chiropractic will begin charging 1% monthly compound interest for the first full month without payment, and every month thereafter.
    • The patient can choose, at any time, to make payments larger than $50.00 or to pay the balance in full.
    • The patient understands that if he/she chooses to make these $50.00 payments to Unison Chiropractic, it will not affect the outcome of settlement of any personal injury claims being made.
    • If the patient has two or more personal injury claims simultaneously in which Unison Chiropractic has agreed to waive payment until settlement, $50.00 for EACH claim must be received monthly for Unison Chiropractic to waive interest on each account.

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  • I have read and understand the above waiver. I choose, however, to have interest charged to my account at a rate of 1% compounded monthly. I understand that once this interest has been charged to my account, it will not be removed, even if I decide at a later date to begin making payments. I direct my attorney or claims adjuster to pay all such interest charges from any settlement, judgement, or verdict, regardless of the amount which I will receive for my personal injuries.

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