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New Patient Forms
Patient Information

This questionnaire was designed to provide important facts regarding the history of your pain or condition. The information you provide will assist in reaching a diagnosis. This form relies on the accurate information you provide.
Name *

First Name Last Name
Your Chiropractor's Name *
Date of Accident *

Month Day Year
Date
Gender *

Male Female
Date of Birth *

Month Day Year
Date
Social Security Number *
Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell Phone Number *

Area Code Phone Number
Home Phone Number

Area Code Phone Number
Email *
example@example.com
Martial Status *

Single Married Divorced Widowed
Occupation
Insurance Information

If you are unsure of claim #, please put a 0 to be able to submit form. However, please note a claim # is needed to bill your auto insurance for our services.
Auto Insurance Company *
Claim # *
Attorney Information

If you do not have an attorney please put N/A or none to be able to submit form.
Attorney / Firm Name *
Attorney Phone Number

Area Code Phone Number
Accident Information
What is the cause of your pain or condition? *

Automobile Accident Motorcycle Accident Struck By A Vehicle As A Pedestrian Struck By A Vehicle As A Bicyclist
Were you the *

Driver Front Seat Passenger Back Seat Passenger - R Side Back Seat Passenger - L Side Back Seat Passenger - Middle Seat
Was your vehicle stopped or moving at the time of impact? *

Stopped Moving
Did you strike another vehicle or object *

Yes No
What Part Of Your Vehicle Was Hit? [You may select multiple if needed]. *

Rear Front Drivers Side Passengers Side
Were you wearing a seatbelt? *

Yes No
Did You Go To The ER? *

Yes No
If Yes, Did The ER Admit You?

Yes No
If Admitted, What Was The Day The ER Discharged You?

Month Day Year
Date
What Was The Day You First Started Treatment For Your Accident? *

Month Day Year
Date
Are you getting therapy? *

Yes No
How many times per week? *

1x Weekly 2x Weekly 3x Weekly
Are you able to work? *

Yes No
Are you able to sleep at night without pain/discomfort? *

Yes No
Is there any other information that is important to know about your accident/conditions?
Current Health Issues
Tobacco Use *

Yes No
Alcohol Use *

Yes No
List Any Allergies To Medications: [If None, Put N/A] *
List Any Current Medications You Are Taking [Please Include OTC Meds As Well, Such as Tylenol/Advil, Etc] - [If None, Put N/A] *
Authorizations and Agreements

Please read and agree to each section below
CONSENT FOR TREATMENT: I hereby authorize your practice and whomever the health care professionals may designate as their assistant to perform examinations, physiotherapy, physical therapy, and perform noninvasive diagnostic tests. If any unforeseen condition arises in the course of the procedures calling for judgment, procedures in addition to or different from those non-complicated. I further request and authorize this office to perform whatever my treating health care professional deems advisable. The nature and purpose of these procedures have risks involved and the possibility of complications has been fully explained to me. I acknowledge that no guarantee has been made to me as the result that may be obtained. INITIAL TO AGREE *
Type Initials
RELEASE OF RECORDS: I authorize the release of a full report of examination findings, diagnosis, treatment program, etc. to any referring or treating dentist or physician. I additionally authorize the release of any medical information to insurance companies or for legal documentation to process claims. I understand that I am responsible for all charges for the treatment rendered to me regardless of insurance coverage. This authorization or photocopy hereof will authorize you to furnish all information you may have regarding my condition while under your observation or treatment, including the history obtained, x-rays, physical findings, diagnosis, and prognosis. You are authorized to provide this information in accordance with the automobile personal injury protection law. (Chapter 71-252 F.S.) INITIAL TO AGREE *
Type Initials
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE PRIVACY PRACTICES: I have been presented with a copy of the notice of privacy practices as made available on detailing how my health information may used and disclosed as permitted under federal and state law and outlining my rights regarding my health information. INITIAL TO AGREE *
Type Initials
PAYMENT AGREEMENT: I understand and agree that health and accident policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that Primacare EMC, LLC will prepare any necessary reports and forms to assist me in making collection for the insurance company and that any amount authorized to be paid directly to Primacare EMC, LLC will be credited to my account upon receipt. However, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment, except for those covered by the Assignment of Benefits. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered to me will be immediately due and payable. INITIAL TO AGREE *
Type Initials
ASSIGNMENT OF BENEFITS, LIENS, DIRECT PAYMENT AUTHORIZATION, AUTHORIZATION TO RELEASE INSURANCE INFORMATION, AND AUTHORIZATION TO ESCROW UNPAID MEDICAL & PIP BENEFITS For and in consideration of Primacare EMC, LLC agreeing to pursue the responsible automobile insurance carrier for payment of benefits due and not requiring prepayment for services, I hereby irrevocably assign all rights and benefits to Primacare EMC, LLC for Personal Injury Protection, extended Personal Injury Protection, Medical Payment Coverage, and other benefits which I may have in accordance with Florida Statute §627.736. This includes any benefits from my insurance company and any other entity which may be responsible for medical expenses incurred. I further authorize Primacare EMC, LLC to collect payments & prosecute any necessary actions to collect payment for services as they see fit and allowable by law and contract. THIS DOCUMENT CONSTITUTES AN ASSIGNMENT OF RIGHTS AND BENEFITS. I hereby further give a lien to Primacare EMC, LLC against any and all insurance benefits named herein, and any and all proceeds of any settlement, judgment or verdict which may be paid to me as a result of the injuries or illness for which I have been treated by Primacare EMC, LLC as a result of the above stated loss date. This document acts as an irrevocable absolute assignment of my rights and benefits to the extent of the charges for services provided. I agree to cooperate with Primacare EMC, LLC and their attorney’s (at their choosing), and to do all things reasonable to effect payment of the billsby the insurance company or other entity to Primacare EMC, LLC including, but not limited to, disclosing my medical condition, being available for factual discovery or other cooperation.This assignment concerns only the bills for Primacare EMC, LLC and those costs including, but not limited to, attorney’s fees, other costs, and interest necessary in procuring payment from the above-named insurance company and/or other entities. This assignment is not intended to assign any other causes of action that may belong to the undersigned patient.I agree to pay any applicable deductible or co-payment not covered by any policy of insurance cited above. I understand that as a benefit and convenience to me, Primacare EMC, LLC will bill and pursue collection against the insurance company or other responsible entity on my behalf. I hereby instruct and direct my insurance company to pay my benefits directly to Primacare EMC, LLC at the address provided on the bill. If my current policy prohibits direct payment to doctors, then I hereby instruct and direct my insurance company or other responsible entity to make the check payable to me and mail it to Primacare EMC, LLC at the address on the bill. Primacare EMC, LLC’s medical care is being provided for a reasonable fee for treatment causally related to the above loss date and is medically necessary. I instruct my insurance carrier or other responsible entity to pay these bills to the full extent of my available benefits under the insurance policy and Florida law. If any portion of the charge for these services is cither reduced or denied in whole or in part, my insurance company or other entity is to place funds equal to the amount of the reduced or denied charges into escrow and hold the escrowed funds until agreement or resolution of legal action by Primacare EMC, LLC I further instruct my insurance company to make payment for charges submitted by Primacare EMC, LLC in priority to any other requests to escrow benefits, including a request by myself to reserve benefits for pending disability claims. I hereby give Primacare EMC, LLC limited power of attorney to endorse and sign my name on any draft for payment to either Primacare EMC, LLC or myself if said draft represents payment for charges related to services rendered by Primacare EMC, LLC. I further direct my insurance carrier or responsible other entity to provide information to Primacare EMC, LLC which is otherwise available to me including but not limited to a copy of any applicable insurance policy, declaration page, all applicable endorsements, transcripts and/or copies of any recorded statements, examinations under oath and requests for same, independent medical evaluations and requests for same, peer review reports, and a listing of all PIP benefits paid to date which shall include when claims were made, when the claims were received, the payment or denial of each claim, the amount of the deductible and the claims applied thereto, and whether benefits have been exhausted and the amount of PIP benefits available, commonly known as a “PIP log”. This request includes the name of other medical providers to whom payments have been under my policy of insurance. This agreement is intended to serve as an assignment of rights and benefits under my policy of insurance in favor of Primacare EMC, LLC. If any language within this agreement has the effect of invalidating this agreement, that language shall be deemed void and the remainder of the assignment shall maintain full force and effect. A photocopy of this assignment shall be considered as effective and valid as the original. INITIAL TO AGREE *
Office of Insurance Regulations

Click/tap on the blue box area on the form and type in your name as an electronic signature.
The form below (OIR-B1-1571) utilizes your ELECTRONIC SIGNATURE. In the blue highlighted fields provided, you will type your name twice, once in the "Print Name" field and again in the "SIGNATURE FIELD", followed by the date.
*
I have provided my ELECTRONIC SIGNATURE within the Office of Insurance Regulation - Standard Disclosure and Acknowledgement Form (PICTURED ABOVE), pursuant to Florida Statutes §§ 668.001–006 INITIAL TO AGREE *
SIGNATURE
I hereby certify all above statements are accurate and provided with my full consent and agreement. *

I Agree
Signature *

If you are using a Tablet or Phone to complet Clear
I have provided my signature in the above box using: *

Computer/Laptop Mouse Phone Tablet
Today's Date *

Month Day Year
Date
Should be Empty:

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Video EMC

Patient Information

Insurance Information

Attorney Information

Accident Information

Current Health Issues

Authorizations and Agreements

Office of Insurance Regulations

SIGNATURE