Personal Injury Protection Packet

PIP / LOP Patient Application Form

Welcome to our clinic. We specialize in assisting our patients in achieving their highest level of health through our spinal and postural correction programs. Our approach is very different and more complete than other rehabilitative programs, which allows us to achieve superior correction as compared to other systems. Please fill out the following information completely so the Doctor can let you if we can accept your case.

Please feel free to ask any questions if you need assistance. We look forward to serving you.

Patient Name

Patient Signature

Date

Electronic Health Records Intake Form

In compliance with Medicare requirements for the Government EHR incentive program

First Name:

Last Name:

Email address

Preferred method of communication:

Email Phone Text Mail

DOB:

Gender:

Male Female

Preferred Language:

CMS requires providers to report both Race and Ethnicity

Race:

American Indian or Alaskan Native Asian Black or African American White or Caucasian Native Hawaiian or Pacific Islander I decline to answer

Other:

Ethnicity:

Hispanic or Latino Non-Hispanic or Latino I decline to answer

Are you currently taking any medications?

Yes No

(Please include regularly used over-the-counter medications)

Add new row

Do you have any medication allergies?

Yes No

Add new row

I choose to decline receipt of my clinical summary after every visit (These summaries are often blank as a result of the nature and frequency of Chiropractic care)

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature:

Date:

Please list all past surgeries and associated dates:

Add new row

Please list any previous accidents and injuries, with associated dates:

Add new row

Please list any prior health health conditions not mentioned:

Add new row

Health Lifestyle

Do you exercise?

Yes No

How often?

1x 2x 3x 4x 5x

Per:

week Month

Smoker status?

Every day smoker Occasional smoker Former Smoker Never smoked

If a smoker, what is your daily usage?

<5 daily 5-10 daily 11-15 daily 15-20 daily >1 pack daily

Do you drink alcohol?

Yes No

What and how much?:

Do you drink coffee?

Yes No

How many cups per day?

Do you drink soda?

Yes No

How many 12oz servings per day?

Do you drink water?

Yes No

How much per day?

Yes No

How many servings per day?

Do you take any supplements? (ie: vitamines, minerals, herbs)

Yes No

Please list:

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature:

Date

Case History

Name:

Age:

Today’s Date:

Address:

City:

State

Zip

Phone (Home):

Sex:

Marital Status:

Single Married Divorced Widowed

Social Security #:

Drivers License #:

State:

Occupation:

Employer:

Phone (Work):

Insurance Company:

Insured’s Name:

(if different from Patient)

Insured’s Date of Birth:

Insurance Contact #:

Insured’s ID # or SS #:

Issuing State:

Spouse’s Name:

Spouse’s contact #:

Present condition due to an injury?

Yes No On the Job Auto Accident

Other:

Has the accident been reported?

Yes No To Employer? Auto Carrier?

Other:

Health Report

Reason for seeking care:

List any other doctors seen for this:

List any diagnosis:

Explain:

Have you had similar accidents or injuries before?

Yes No

List names of relatives that have had a smiliar problem:

Have you or any relatives received chiropractic treatment previously?

Yes No

If yes, please explain:

Have you been treated by a physician in the last year for any reason?

Yes No

If yes, please explain:

If you listed any medications on EHR page, please list each condition those medications are prescribed for:

Do you exercise?

Yes No

How often?

1x 2x 3x 4x 5x

Per:

Week Month

Smoker status?

Every day smoker Occasional smoker Former Smoker Never smoked

If a smoker, what is your daily usage?

<5 daily 5-10 daily 11-15 daily 15-20 daily >1 pack daily

Do you drink alcohol?

Yes No

What and how much?:

Do you drink coffee?

Yes No

How many cups per day?

Do you drink soda?

Yes No

How many 12oz servings per day?

Do you drink water?

Yes No

How much per day?

Do you eat fruits and vegetables?

Yes No

How many servings per day?

Do you take any supplements? (ie: vitamines, minerals, herbs)

Yes No

Please list:

Circle your current degree of pain: 0 1 2 3 4 5 6 7 8 9 10+

Using the symbols below, mark on the diagram where you feel pain

Numbness =

Dull Ache 0

Burning x

Sharp, Stabbing /

Pins, Needles +

Other ???

What activities exacerbate (irritate) your symptoms?

Is this condition worse during certain times of the day?

Is this condition interfering with

Work Sleep Daily Routine Other

Other

Is this condition progressively getting worse?

Yes No

Please mark each item below for each condition/ symptom you currently have or previously had:

General Symptoms:

Convulsions

Dizziness

Fainting

Headache

Nervousness

Numbness

Wheezing

Respiratory:

Asthma

Chronic Cough

Difficulty Breathing

Spitting Blood

Spitting Phlegm

Genito-Urinary:

Blood in Urine

Frequent Urination

Kidney Infection

Painful Urination

Prostate Problems

Loss of Bladder Control

Skin or Allergies:

Boils

Bruising Easily

Dryness

Eczema/ Rash/ Dermatitis

Hives

Itching

Sensitive Skin

Allergy

For Allergy

I hereby certify that the answers given on this form are accurate to the best of my knowledge, and understand it is my responsibility to inform this office of any changes in my health. I agree to allow this office to examine me for further evaluation relative to my treatment.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature:

Date

Terms of Acceptance

Procedures and Payment Policy

When a person seeks chiropractic care and rehabilitative health care, and is accepted for such care, it is essential for both parties to be working towards the same objective. It is important that each person understand both the objective and the method(s) that will be used to obtain this objective. By signing this form, you acknowledge that you have read, understand, and consent to the terms herein.

Procedures

No Charge Consultation: This is a brief meeting between you and the Doctor to determining if you may benefit from the care we provide. There is no financial obligation in connection with this service.
Clinical Exam: After your consultation, if the Doctor believes you will likely benefit from the care we provide, a thorough orthopedic, neurologic, and chiropractic clinical exam will be recommended.
X-Rays: Based on the exam findings, the Doctor may recommend selected x-rays be taken to aid in comprehensive diagnosis of your condition(s).
Included in the cost of the clinical exam is a report of findings. This is where the Doctor presents his findings regarding your diagnostic testing. The Doctor will also explain what he feels would be the best and fastest approach to improve your health, based on your condition.
Treatments may include: Spinal and extraspinal adjustments, joint manipulation, intersegmental traction, electric muscle stimulation, curve restoration traction, core muscle training, posture correction exercises, scoliosis correction therapy, cold laser therapy, rehabilitation therapy, spinal decompression, massage/ manual therapy, ice (cryotherapy), neuromuscular re-education, custom orthotics, analgesic rubs/ creams/ sprays, and nutritional recommendations and supplements.

Payment Policy

Payment is expected at the time of service, unless prior arrangement has been made between you and the office.
Health/ Automobile Insurance

Your insurance coverage is a contract between you and your insurance company. We will gladly help you verify benefits of your particular coverage; however, we cannot take responsibility for what your insurance does or does not cover. Ultimately, all services rendered to you are charged directly to you, and you are responsible for any and all payment aside from benefit coverage approved by your insurance carrier.
We will file your insurance claim for you and do everything we can to ensure you receive proper reimbursement, if applicable.
If your policy has a deductible feature, it is due at the time of service.
We will do our very best to answer any questions you may have in regard to your insurance.

There will be a $25 charge on all returned checks (plus the original amount of the check)

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature:

Date

Informed Consent

Signing below indicates a request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various methods of physiotherapy and, if necessary, diagnostic x-rays on me by the Doctor of Chiropractic and/ or by any other office or clinic personal.

Possible Risks

I understand and am informed that, as in all healthcare, in the practice of Chiropractic medicine there are some risks to treatment. These risks include but may not be limited to: stiffness, soreness, muscle strain, ligament sprain, fracture, disc injury, dislocation, paralysis, and stroke. The ancillary procedures could produce skin irritations, burns, or minor complications.

Probability of Risks

Occurring The risk of complications due to Chiropractic treatment have been described as rare, about as often as complications are seen from the taking of a single Aspirin tablet. The risk of cervicobrachial injury or stroke has been estimated at one in one million to one in twenty million, and can be reduced even further by screening procedures. The probability of adverse reaction due to ancillary procedures is also considered rare.

Other Treatment Options that Could Be Considered

Over-the-counter analgesics. The risks of these medications include irritation to stomach, liver and kidneys, and other side effects in a significant number of cases.
Medical care, typically anti-inflammatory drugs, tranquilizers, steroids, and analgesics. Risks of these drugs include a multitude of undesirable side effects and patient dependence in a significant number of cases.
Hospitalization in conjunction with medical care adds risk of virulent communicable disease in a significant number of cases.
Surgery in conjunction with medical care adds the risk of adverse reaction to anesthesia, as well as an extended convalescent period in a significant number of cases.

Consent

I acknowledge I have discussed, or have had the opportunity to discuss, with my Chiropractor the nature and purpose of Chiropractic treatment in general and my treatment in particular (including spinal adjustment) as well as the contents of this Informed Consent waiver. I consent to the chiropractic treatments offered or recommended to me by my Chiropractor. I intend this consent to apply to all my present and future chiropractic care.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Print Patient Name

Date

Sign Patient Name

Notice of Privacy Practice

Authorization for Use or Disclosure of Protected Health Information

We keep a record of the health care services provided to you. You may ask to see a copy of that record. We will not disclose your records to others unless you direct us to, or unless the law compels or requires us to. You may see your record or get more information about it by contacting one of our offices. We may use your health information in the following ways:

We may share your health information to run our office, collect payment, treat you, thank you for referring others, discuss your case with your family, include you in health care classes, help you collect from your insurance company, inform you about other services, or provide assistance with your diagnoses or treatment from another provider or radiologist.
We may use your health information for health and safety reasons, court hearings and filings, reporting to law officials, and for reporting victims of abuse.
We may call you by name in the reception area when the doctor is ready to see you.
A postcard may be mailed to the address provided by you.
When telephoning your home, we may leave a message on your answering machine or whomever answers when we call.
We may include a photo of you on our referral wall.

You have the right to- request a copy of your records, ask to limit the information we share, amend your health information, or request a list of whom we share your records with. You have the right to revoke this authorization in writing at any time, except to the extent that the information has been released in reliance upon this authorization. Our office follows legal and ethical standards pursuant to HIPAA compliance at all times regarding your protected health information.

Please advise our management if you believe your privacy rights have been violated.

By signing below, you consent to our use and disclosure of your protected healthcare information as indicated above and as required by law, and you acknowledge that you have read, understand, and agree to our Notice of Privacy Practices.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Name (Print)

Date

Patient Name (Sign)

No-Call / No-Show Policy

I (Please input Name below) acknowledge that TLC Family Medical & Wellness Center will charge a fee of $25 for every missed appointment that is not cancelled or rescheduled at least 24 hours in advance. This balance will accrue for each missed appointment, and the total will be forwarded to my attorney upon settlement of my case. To avoid these charges, I understand that I must call at least 24 hours in advance to cancel or reschedule any appointment that I am unable to keep.

Name:

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature

Date

Staff Signature

X-ray/ Diagnostic Testing Consent

During the examination the Doctor may feel that additional scans and diagnostic tests will be needed in order to further assess and diagnose your condition. We would like to make you aware that, in those cases, additional x-rays and/ or diagnostic tests may be required in order to accurately diagnose your condition and administer treatment. In order to perform x-rays on any patient, our office requires consent for such tests to be performed.

Please choose one:

I understand that my Doctor may need x-rays or diagnostic tests in order to diagnose my condition and I give my consent for all necessary scans and tests. I understand that my condition may require my Doctor to take x-rays to further diagnose my symptoms. I choose not to consent to additional scans or diagnostic tests at this time, and release the Doctor and Family Chiropractic Health Centers of all liabilities that may arise.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature

Date

Staff Signature

Date

PIP/ MVA Questionnaire

Date of Accident

What type and size vehicle were you driving?

Bicycle

Car

Mini Small Midsize Large

SUV

Small Medium Large Very Large

Pickup Truck

Small Large Very Large

Tractor Trailer

With Load Without Load Unknown if Loaded

Your position in vehicle:

Driver

Front Passenger

Rear Left

Rear Middle

Rear Right

Were you seated in a:

Booster Seat Car Seat

What type and size of the other driver’s vehicle?

Bicycle

Car

Mini Small Midsize Large

SUV

Small Medium Large Very Large

Pickup Truck

Small Large Very Large

Tractor Trailer

With Load Without Load Unknown if Loaded

Were you wearing your seatbelt?

Yes No

Did your airbag deploy?

Yes No

Did your seat break in the impact?

Yes No

Your headrest position relative to your head?

Low Mid High Headrest not present

Did your head hit the headrest?

Yes No

Your head position at impact?

Ahead Down Left Right Over left shoulder Over right shoulder

Did the impact cause any body part to strike any object in the car?

Yes No

Which part of automobile?

Airbag Armrest Dashboard Door Flying object(s) inside vehicle Headrest Seat Steering wheel Window

Did you receive a head injury from this accident?

Yes No

Did you lose consciousness?

Yes No

Where was your vehicle impact location?

Front right

Front left

Front center

Right rear

Left rear

Rear end

Right side (passenger’s side)

Left side (driver’s side)

Treated by self at home:

Radio buttons

With heat With cold With OTC medication With rest

Where were your primary (most apparent) symptoms felt at the time of accident?

Insurance Information

Patient’s Full Name:

Social Security # :

Street Address:

City:

State:

Zip:

Patient’s Personal Insurance:

Policyholder’s Name

(If other than patient):

Policy # :

(If other than patient):

Insurance Company Name:

Insurance Contact Phone # :

Street Address:

City:

State:

Zip:

Claim # :

Attorney’s Name:

Adjuster’s Name:

Contact # :

Other Party’s Insurance:

Additional Insurance:

Patient Name:

Date:

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 mark the one statement that most closely describes your problem.

Index Score = [Sum of all Statements Selected / ( # of selections with a statement selected x 5 )] x 100

Net Index Score

Patient Name:

Date:

Index Score = [Sum of all Statements Selected / ( # of selections with a statement selected x 5 )] x 100

Net Index Score

Standard Disclosure and Acknowledgement Form

Personal Injury Protection- Initial Treatment or Service Provided

The undersigned insured person (or guardian of such person) affirms:

The services or treatment set forth below were actually rendered. This means that those services have already been provided.

2. I have the right and the duty to confirm that the services have already been provided.

3. I was not solicited by any person to seek any services from the medical provider of the services described above.

4. The medical provider has explained the services to me for which payment is being claimed.

5. If notify the ensurer in writing of a billing error, I may be entitled to a portion of any reduction in the amount paid by my motor vehicle insurer. If entitled, my share would be at least 20% of the amount of the reduction, up to $500.

Insured Person (patient receiving treatment or services) or Guardian of Insured Person:

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Name (PRINT or TYPE)

Signature

The undersigned licensed medial professional or medical director, if applicable, affirms the statement numbered 1 above and also:

A. I have not solicited or caused the insured person, who was involved in a motor vehicle accident, to be solicited to make a claim for personal Injury Protection benefits.

B. The treatment or services rendered were explained to the insured person, or his or her guardian, sufficiently for that person to sign this form with informed consent.

C. The accompanying statement or bills is properly completed in all material provisions and all material provisions and all relevant information has been provided therein. This means that each request for information has been responded to truthfully, accurately, and in a substantially complete manner.

D. The coding of procedure on the accompanying statement or bill is proper. This means that no service has been upcoded, unbundled, or constitutes an invalid or not medically necessary diagnostic test as defined by Section 627.732 (15) and (16), Florida Statutes.

Licensed Medical Professional Rendering Treatment/Services or Medical Director, if applicable (Signature by his/her own hand):

Short textName (Print or TYPE)

Signature

Date

Hippa Release of Patient Records Authorization

I (Please Input name below)

hereby authorize, (please input name below)

to release a copy of all my records/reports containing proceeded information to : Dr David K. Dahmer, DC or Dr Christian Schneider DC for Date of Service:

Date

The authorization is given pursuant of Florida statutes 456.051(10) makes clear that any third party to whom records are disclosed in prohibited from further disclosing any information in the records without the expressed written consent of the patient or the patient’s legal representatives.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Print: Patient/Legal rep. Name:

Signature: Patient/Legal rep. Name:

Patients last 4 of SSN:

Patients DOB:

Date

Re: Health Reports and Doctor’s Lien

Name of Attorney:

I hereby authorize and direct my attorney, to pay directly to TLC Family Medical and Wellness Center, such sums as may be due and owing for professional services rendered to me both by reason of this accident and by reason of any other bills that are due to the provider and to withhold such sums from any settlement of judgment as is necessary to adequately protect the provider. I hereby further give a lien to the provider on any proceeds to which I may become entitled as a result of any settlement of judgment in any claim or litigation arising out of the injuries for which I have been treated of injuries in connection therewith, whether such proceeds are remitted directly to me or to you my attorney. I fully understand that I am directly responsible to the provider for all professional bills submitted by the provider for services rendered to me by the provider and that this agreement is made solely for the providers’ additional protection and in consideration of the provider awaiting payment. I further understand that such payment is not contingent on any settlement, judgment or verdict by which I may eventually recover said fee. Attorney agrees to notify the doctors immediately of the name and contacting information of any attorney substituted in his or her place.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Print Name:

Sign:

Date of Accident:

Today’s Date:

ACKNOWLEDGEMENT OF ASSIGNMENT & LIEN BY ATTORNEY

The undersigned being the attorney of record on his own behalf and on behalf of any other attorney or attorneys who are associated with the undersigned or who are substituted in his stead 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, TLC Family Medical & Wellness Center.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Attorney Signature:

Date:

* NOTE TO ATTORNEY* PLEASE SIGN AND RETURN ONE COPY TO THE PROVIDER’S OFFICE; KEEP A COPY FOR YOUR RECORDS

Medical Release

Photocopy of this document shall be sufficient to authorize any person having records of medical treatment, services or supplies pertaining to me to be true copies of same to TLC Family Medical & Wellness Center Inc. or any insurer providing coverage to me in connection with the processing of any claims for benefits made by me or by the assignee herin. A photocopy of this document shall be as binding as an original signature page.

The undersigned does herby ratify and confirm any and all actions taken by the said attorney in accordance with this special power and which they said attorney shall do or cause to be done by virtue of these presents.

Release of information: I herby authorize this medical provider to furnish my insurance company or companies and the patient’s attorney with any and all information that may be contained in my medical records, to obtain coverage information telephonically from my insurer; to request a written non redacted PIP payout sheet from the insurer; and to obtain copies of my medical records, including but not limited to, documents, reports, scans, notes, options, x-rays, anf MRI’s received from any other medical provider or any insurance company. The insurer is directed to keep the patient’s medical records private and confidential. The insurer is NOT authorized to provide these medical records to anyone, including but not limited to, third party vendors without the patient’s and the provider’s express written permission.

Assignment of Benefits

I, (Please input name below)

(Name of insured)

Herby authorize (Please input name below)

(Name of Insurance Carrier)

Payable directly to: TLC Family Medical & Wellness Center Inc.

Payable to and mail directly to: 13315 Cortez Blvd. Brooksville, FL. 34613

Herby IRREVOCABLY ASSIGN to TLC Family Medical & Wellness Center Inc. any benefits under any policy of insurance, indemnity agreement, or any other collateral source as defined in Florida Statutes for any services and/ or charges provided by TLC Family Medical & Wellness Center Inc. IN WITNESS WHEROF the undersigned have here unto set their hands, this_____ day of ________________, 20____. (Please input date below)

Date

(Print Name)

(Sign Name)

Your information will be encrypted.