Personal Injury Questionnaire
Name ______
Email ______
Social Security Number______
Street Address ______
City ______State ______Zip ______
Cell Phone ______Work Phone ______
Age ______Date of Birth______Sex_____
Employer’s Name ______Employer’s address______
Your ins. Co. ______Policy #______Driver’s License# ______
Agent’s Name______
Phone # ______
Major Medical Ins.? (Yes) (No) Co. Name ______
Policy #______Phone # ______
Driver/Other Vehicle ______Ins. Co. ______
Policy # ______Phone # ______
Have you retained an Attorney? (Yes) (No) Name______Phone # ______
Were there any witnesses? (Yes) (No) Names______
NATURE OF ACCIDENT
1. Date of Accident ______Time of Day ______
2. Were you: ( ) Driver ( ) Passenger ( ) Front Seat ( ) Back Seat
3. Number of people in you vehicle ______Other vehicle ______
4. Were you struck from: ( ) Behind ( ) Front ( ) Left Side ( ) Right Side
5. Were you wearing a seat belt? (Yes) (No)
6. Approximate speed of you car: ______mph Other Car: ______mph
7. Were you knocked unconscious? (Yes) (No) If yes, for how long? ______
8. Were police notified? (Yes) (No)
9. Where were you taken after the accident? ______
10. In your own words, please describe accident in detail:______
11. Did you have any physical complaints BEFORE THE ACCIDENT? (Yes) (No) If yes, please explain: ______
12. Describe how you felt:
a. DURING the accident ______
b. IMMEDIATELY AFTER the accident: ______
c. LATER THAT DAY:______
d. THE NEXT DAY: ______
e. THE FOLLOWING WEEK:______
What are your PRESENT complaints and symptoms
13. Do you have any congenital (from birth) factors that relate to this problem? (Yes) (No) If yes, please______describe:______
14. Do you have any previous illnesses which relate to this case?______
15. Have you ever been involved in an accident before? (Yes) (No) If yes, please describe, including dates(s) and types of accidents, as well as injury(ies) received:______
16. Have you been treated by another doctor since the accident? (Yes) (No) If yes, please list the doctor’s name and address:______what type of treatment did you receive?______
17. Since the injury occurred, are your symptoms: ( ) Improving ( ) Getting Worse ( ) Same
18. CHECK THE SYMPTOMS YOU HAVE NOTICED SINCE THE ACCIDENT:
ð Headache ð Irritability ð Numbness in Toes ð Face Flushed ð Feet Cold ð Neck Pain
ð Chest Pain ð Shortness of Breath ð Buzzing in Ears ð Hands Cold ð Neck Stiff
ð Dizziness ð Fatigue ð Loss of Balance ð Stomach Upset ð Sleeping Problems ðHead Seems too
ð Heavy Depressionð Fainting ð Constipation ð Back Pain ð Pins & Needles in Arms
ð Light Bother Eyes ð Loss of Smell ð Cold Sweats ð Nervousness ð Pins & Needles in Legs
ð Loss of Memory ð Loss of Taste ð Fever ð Tension ð Numbness in Fingers
ð Ears Ringing ð Diarrhea
Symptoms other than the above:______
19. Have you lost time from work as a result of this accident? (Yes) (No) If yes, please complete this question.
f. Last day Worked: ______
g. Type of Employment: ______
h. Are you being compensated for lost time from work? (Yes) (No) If yes, please state type of compensation you are receiving:______
20. Do you notice any restrictions as a result of this injury? (Yes) (No) If yes, please describe in detail
:______
21. Other pertinent information:
______
How did you hear about us?
ð Patient Referral ______ð Other______
ðYellow Pages ð Internet ð Shepherds Guide
______
______
Date Patient’s Signature
Terms of Acceptance
When a person seeks Chiropractic care and we accept a person for such care it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is important that each person understands both the objective and the method that will be used to attain it. This will prevent confusion.
Adjustment: A specific application of forces to facilitate the body’s correction of the vertebral subluxation. Our chiropractic method of correction is by specific adjustments to the spine.
Health: A state of physical, mental and social well-being; not merely the absence of disease or infirmity.
Vertebral Subluxation: A misalignment of one or more of the 24 vertebrae in the spine resulting in nerve dysfunction, resulting in the lessening of the body’s innate ability to express its maximum health potential.
We do not offer to diagnose or treat any disease. Our focus in this office is the vertebral subluxation. However, if we encounter non-chiropractic or unusual finings we will advise you. If you desire advice, diagnoses, or treatment for the aforementioned findings we recommend that you seek another healthcare provider.
Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. Our ONLY PRACTICE OBJECTIVE is to locate, analyze and correct vertebral subluxation by specific adjustments.
I ______have read and fully understand the above statements.
(Print name)
All questions regarding the chiropractor’s objectives to my care in this office have been answered to my complete satisfaction. I therefore accept care on this basis.
Signature______Date______
CONSENT TO EVALUATE AND ADJUST A MINOR
I, ______being the parent or legal guardian of ______have read and fully understand the above terms of acceptance and hereby grant permission for my child to receive Chiropractic care.
Signature ______Date______
Pregnancy Release
This is to certify that to the best of my knowledge I am not pregnant and the above doctor and his/her staff have my permission to perform X-rays. Date of last menstrual period: ______
Signature ______Date______
Patient Health Information Consent Form
We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we will begin any health care operations we must require you to read and sign this consent form stating that you understand and agree with how your records will be used.
1. The patient understands and agrees to allow this chiropractic office to use their Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operations, and coordination of care. As an example, the patient agrees to allow this chiropractic office to submit requested PHI to the Health Insurance Company (or companies) provided to us by the patient for the purpose of payment. Be assured that his office will limit the release of all PHI to the minimum needed for what the insurance companies require for payment.
2. The patient has the right to examine and obtain a copy of his or her own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restriction on the use of their PHI. Our office is not obligated to agree to those restrictions.
3. A patient’s written consent need only be obtained one time for all subsequent care given the patient in this office.
4. The patient may provide a written request to revoke consent at any time during care. This would not effect the use of those records for the care given prior to the written request to revoke consent but would apply to any care given after the request has been presented.
5. Patients have the right to file a formal complaint with our office about any possible violations of these policies and procedures.
6. If the patient refuses to sign this consent for the purpose of treatment, payment and health care operations, the chiropractic physician has the right to refuse to provide care.
I have read and understand how my Patient Health Information will be used and I agree to these policies and procedures.
Name of Patient Date
Financial Policy
Please take a few minutes to review the following information prior to your appointment.
We hope you understand that our financial policies are established to assure the financial resources needed to maintain this chiropractic office for all of our patients. We will work with you to ensure that your chiropractic care down not become a financial burden.
Charges for services are due and payable at the time of service regardless of your insurance status. We accept cash, personal checks, and credit cards for payment on your account.
About Health Insurance
Your insurance policy is an agreement between you and your insurance company. Our relationship is with you, not with your insurance company. Therefore, all charges are ultimately your responsibility, regardless of your insurance status.
If you have selected Cooley Chiropractic because we are on your plan, be aware that we have done this as a service to your. We will bill your insurance company for services rendered at our clinic. Regardless of our association with our insurance, whatever amount they do not pay towards our services, you are still responsible for.
Signature______Date ______
Cooley Chiropractic Financial Program
*We require payment at time of service*
**Insurance is accepted and billed by our office** (Please provide us with a copy of your card)
If we are unable to verify insurance coverage on your initial visit, then we ask you to pay for that visit and we will adjust your bill accordingly after insurance if verified.
If you are unable to pay the bill in the full amount, please refer to payment option #2 and #3 below
Payment Options: please check one.
1. ð Per visit – cash, check, credit, or debit.
2. ð Full payment automatically of my balance at the beginning of each month.
3. ð In effort to provide care for everyone, we offer a monthly payment plan that automatically debits from your credit or debit card account on the beginning of each month. You determine an amount (no less that $75) you would like to have withdrawn.
ð Monthly payment of $______per month beginning ______1st, 2011 automatically.
Only payment options 2 and 3 require information below to be completed
ð I agree to register my Debit Card or Credit Card number confidentially.
TYPE OF CARD______EXP DATE______NUMBER______
NAME AS IT APPEARS ON CARD______
3 I agree to submit a series of Post-Dated Checks in the amount I have chosen above
BANK NAME______
ACCOUNT NUMBER______ROUTING NUMBER______
I GIVE PERMISSION TO CHARGE MY DEBIT CARD, CREDIT CARD______/9INITIALS) OR CHECKING ACCOUNT.
SIGNATURE______DATE______
Notice to all personal injury patients
Please be advised that all charges to the Cooley Chiropractic Clinic for chiropractic care during your personal injury case are due and payable upon completion of your care.
Any funds released to you (checks payable to you from the insurance company) are payable to the clinic until your account is paid in full. We will accept insurance checks that are endorsed by you or a personal check from you.
Third party insurance
We are willing to treat you under Third Party insurance until your case settles. Once you have completed care, if settlement is not reached in 90 days, we ask that you make regular payments on your case. A payment schedule can be created upon request.
Personal Injury protection insurance (PIP)
If you receive checks for your treatment at our clinic, they are to be signed over to us upon receipt.
Patient Policy: Doctor-Patient Agreements
Welcome to Cooley Chiropractic! The purpose of these agreements is to allow us to more completely serve you and to get the best results in the shortest amount of time. It is our experience that those patients who adhere to the following agreements get the best results.
Missing or Changing Appointments
We will set up a specific course of adjustments for you. A certain number of adjustments are necessary for us to get the results we both desire. Thus, keeping your scheduled appointment is imperative! If you cannot make your scheduled appointment, please call us and let us know and we will get you rescheduled.
Payment of Bills
We expect you to honor the financial agreement you make with our office. If you find you cannot fulfill the agreement you made with us, advise us immediately so new arrangements can be made. We have payment plans.
Upsets
We are here to serve you and your family. Please speak with Dr. Cooley about anything that is upsetting you about our policies or service. We see your comments as helping us to help you and others
Referrals
We ask that you consider us for referrals to your friend and family. It is important to us to deliver the message of true health to the community and we ask for your help in doing so.
policies.
I have read the above and understand and accept these
Patient Signature Date
AUTHORIZATION TO RELEASE OR RECEIVE MEDICAL INFORMATION
AND
AUTHORIZATION OF ASSIGNMENT OF BENEFITS
We strongly feel that all patients deserve from us the very best chiropractic care that we can provide. Further, we feel that everyone benefits when definitive financial arrangements are agreed upon. Accordingly, we have prepared this material to acquaint you with our policy.
Our professional services are rendered to you, not the insurance company. Therefore, payment for treatment is you responsibility.
1. I hereby instruct and direct the ______insurance company to pay by check made out and mailed directly to:
COOLEY CHIROPRACTIC
6605 PRECINCT LINE ROAD, SUITE 100B
NORTH RICHLAND HILLS, TX 76182
2. I authorize this office to release or receive any information necessary to expedite insurance claims.
3. I hereby authorize this office to bill my insurance company directly for their service.
4. In the event I receive payment from my insurance carrier, I agree to endorse any payment I receive over to Dr. Kent Cooley for which these fees are payable.
5. If I discontinue care before being released by Dr. Cooley, any and all bills are immediately due and payable.
6. If you are a worker compensation patient, your worker compensation carrier is responsible.
I understand that I am directly and fully financially responsible to this clinic for charges not covered by my insurance. I further understand that such payment is not contingent on any settlement, judgment or insurance payment by which I recover said fee. I realize that if my insurance company fails to pay my balance in full, or there is no payment within 60 days, it is my responsibility to pay my doctor’s bill directly.