Telephone: (360) 694-0300
Fax : (360) 694-0301
1610 C St. Ste. 103
Vancouver, WA 98663
www.VancouverSpinalcare.com
Auto Accident Form
Name: ______________________________________________ DOB: _________ Date: ________________
Address: _______________________________ City: ________________ State: _____ Zip Code: _________
Home Phone: ___________________ Cell Phone: ___________________ Work Phone: __________________
Email _________________________ How did you hear about us so we can thank them? __________________
Occupation:_______________________________ #Hours per week currently working________
Have you ever been to a chiropractor before? Yes/No ______My last adjustment was_______
Will you be seeking reimbursement from insurance? Y / N Would you like to check your insurance benefits? Y / N
Spouse’s name: __________________________
Spouse Occupation ________________________
Spouse’s #Hours per week currently working______
Spouse
DOB: _________ Number
of children:
________
Your position in vehicle: Driver_______ Front Passenger________ Right rear passenger________ Left rear passenger________ Other_____ Please Explain:_______________________________________________________________________________ Involved Party vehicle make: ________________________________ Model:_______________________ Year:____________ Name of driver: ________________________________________________________________________________________ Address of driver: _______________________________________________________________________________________ City:_________________________________________ State:____________________ Zip Code:_______________________ Involved Party vehicle make: ________________________________ Model:_______________________ Year:____________ Name of driver: ________________________________________________________________________________________ Address of driver: _______________________________________________________________________________________ City:_________________________________________ State:____________________ Zip Code:_______________________ Has a personal injury protection (PIP) claim been file? Yes:____ No:____ If yes, claim #:______________________________ How much damage was done to the vehicle: $_________________ Have you consulted with an attorney: _________________
Is an attorney representing you? If so please provider contact information below:
Law Office Name:__________________________________________ Attorney Name:________________________________ Phone number: (_______)____________________Address:_____________________________________________________ City:____________________________________ State:________________ Zip Code:________________________________
How did you leave the scene of this accident: Drove same vehicle:_______ By ambulance:_______ By fire department:______ By police:_______ By friend Other:_______ Other:____________________________________________________________ Location of accident:_____________________________________________________________________________________ City:_________________________________________ County:____________________________ State:________________ Was this accident investigated by law enforcement:_____________________________________________________________ If law enforcement did investigate accident what agency: City police:_____ Country police or sheriff:_____ State police:______ Case number:__________________________________________________________________________________________ Did you complete a state accident form:______________________________________________________________________
On below image shade areas of In below box draw to best abilities the accident scene.
impact on vehicle
What was the approximate speed of the vehicle: _____________ Miles Per Hour (MPH)
During accident were you wearing a seatbelt and/or shoulder harness: _____________________________________________ Did a airbag deploy at your position:________________________________________________________________________ Was a headrest available at your position:____________________________________________________________________ At the time of impact, were you aware that an accident was about to occur:_________________________________________ Did you brace for impact:_________________________________________________________________________________ At the time of accident, were you looking: Forward:_________________ Right: _________________ Left: ________________ At the time of accident, were you: Stopped: ____________ Moving Forward: ____________ Moving Backwards: ___________ Did you have a: Traffic light:____________ Stop Sign:____________ Yield Sign:__________ No traffic control:____________ This was a: Head-on collision:_____ Rear-end collision:______ “T-Bone” collision:______ Collision into stationary object:_____ Car-bicycle accident:_____ Car-pedestrian accident:______ Other-Please explain:____________________________________
Date of accident:_______________________________________ Time of accident:_____________________________ AM/PM The weather was: Clear:_______________ Cloudy:________________ Foggy:________________ Other:________________ The road condition were: Dry:________________ Wet:_______________ Icy:_______________ Snowy:_______________ The road surface was: Concrete Asphalt Dirt Gravel
At the time of the accident, it was: Raining:____ Drizzling:____ Snowing:____ Hailstorm:_____ No precipitation – Dry:_____ Did you receive any injuries, bruises, or cuts as a result of the use of seatbelts, shoulder harness, headrest, or airbag
deployment? Please describe:______________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________
Please note on the diagram below any areas of contusions, bruising, cuts, lacerations, or scrapes
Did you experience any of the following symptoms after the accident: Loss of consciousness Low back Pain
Dizziness Low back stiffness
Confusion Blurred vision
Tingling in arms or legs Disorientation
Numbness in arms or legs Warm spots in your body
Neck Pain Cold spots in your body
Neck Stiffness Headaches
Have you had difficulty with any of the following daily activities since the accident:
Sleeping Bathing
Sitting Reading
Walking Concentrating
Eating Bowel movements
Please list any other daily activities that have been affected as a result of this accident:________________________________ _____________________________________________________________________________________________________
How did you leave the scene of this accident: Drove same vehicle:_______ By ambulance:_______ By fire department:______ By police:_______ By friend Other:_______ Other:____________________________________________________________ Location of accident:_____________________________________________________________________________________ City:_________________________________________ County:____________________________ State:________________ Was this accident investigated by law enforcement:_____________________________________________________________ If law enforcement did investigate accident what agency: City police:_____ Country police or sheriff:_____ State police:______ Case number:__________________________________________________________________________________________ Did you complete a state accident form:______________________________________________________________________
It is of the utmost importance that this form be thoroughly completed. Also, please
bring in copies of all reports that were completed either by you or by law
enforcement.
Doctor’s Lien
To Attorney(s) and/or Insurance:
Derrick Hau, D.C.
________________________________________ Kenneth Ransonet, DC.
________________________________________
Scott
Freeman,
D.C.
________________________________________ Vancouver Spinal Care
________________________________________
1610 C Street Suite 103
________________________________________
Vancouver, WA 98663
360.694.0300 phone
Patient’s Name:________________________________________
360.694.0301 fax
Date of Birth: ________________________________________
I do hereby authorize Derrick Hau, D.C. to furnish to you, my attorney and/or insurance with a full report
of his examination, diagnosis, treatment, prognosis, etc., of my self in regard to the accident in which I was
recently involved.
I hereby authorize and direct you, my insurance company, and/or my attorney to pay directly to said doctor
such sums as may be due and owing him for medical service rendered to me both by reason of settlement,
judgment, or verdict as may be necessary to adequately protect said doctor. I hereby further give a LIEN
on my case to said doctor against any and all proceeds of my settlement, judgment or verdict which may be
paid to you, my attorney, or myself as the result of the injuries for which I have been treated or injuries in
connection therewith.
I agree never to rescind this document and that a rescission will not be honored by my attorney. I hereby
instruct that in the event another attorney is substituted in this matter, the new attorney honor this lien as
inherent to the settlement and enforceable upon the case as if it were executed by him.
I fully understand that I am directly and fully responsible to said doctor for all medical bills submitted by
him for service rendered me and that this agreement is made solely for said doctor’s additional protection
and in consideration of his 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.
If my attorney does not wish to cooperate in protecting the doctor’s interest, the doctor will not await
payment but may declare the entire balance due and payable.
Patient’s Signature: ______________________________________ Date:_____________
________________________________________________________________________
Address
City
St
Zip
ATTORNEY(S): Please sign, date and return one copy to doctor’s office and keep one copy for your
records.
The undersigned being attorney of record for the above patient do hereby agree to observe all the terms of
the above and agrees to withhold such sums form any settlement, judgment or verdict as may be necessary
to adequately protect said doctor named. Attorney further agrees that in the event this lien is litigated that
the prevailing party will be awarded attorney fees and costs.
PERSONAL INJURY FINANCIAL POLICY
This is an agreement between Vancouver Spinal Care and the Patient/Debtor named on this form.
In this agreement the words “you,” “your,” and “yours” means the Patient/Debtor. The word “account” means the
account that has been established in your name to which charges are made and payments are credited. The words
“we,” “us,” and “our” refer to Vancouver Spinal Care.
Charges to Account: Upon reaching an agreement with your insurance company or attorney, charges may be
made to your account without payment at time of service during your personal injury claim. We shall have the right to
cancel this privilege at any time if circumstances between this office and your attorney or insurance company
change. When appointments are not made and kept according to your treatment plan, you may be released from our
care due to non-compliance.
Responsibility for Payment
As a courtesy to you, we will gladly submit your charges to your insurance company(ies) and/or your attorney;
however, all services rendered by this office are charged directly to you, and ultimately, you are personally
responsible for payment of these charges, regardless of any insurance reimbursement or settlement you may or may
not receive.
Effective Date: Once you have signed this agreement, you agree to all of the terms and conditions contained
herein and the agreement will be in effect. You may receive a copy of this agreement upon request.
Insurance and payments: While you are under care for your personal injury you authorize us to send your
records and bills to the appropriate companies. (i.e. auto insurance company or attorney) You authorize your
insurance company(s) or attorney to pay benefits directly to Vancouver Spinal Care. If benefits are paid directly to
you the patient, payment for your full bill will be expected promptly after your settlement is reached. Any unpaid
balance over 120 days post settlement will be transferred to our collections agency. If we refer your account to a
collection agency, you agree to pay all of the collection costs that are incurred to you and it will become your
responsibility. The insurance company will make the final determination of your eligibility and amount of the
settlement. If you disagree with any verification or payment on your behalf, it will be your responsibility to pay your
account balance in full. Any discrepancies will be handled between you and your insurance company.
Attorney Liens:
If you hire an attorney to represent you in a law suit, it is our policy to have your attorney sign a Doctor's Lien. This
will guarantee direct payment to our office for any undid balance upon the settlement of your law suit. We retain the
right to first submit all charges to your private and/or auto insurance policy for payment. Further, this office does not
discount or reduce the amount of your balance based upon the outcome of your settlement.
Returned Checks: There will be a $10.00 fee assessed for all returned checks.
I have read and understand the financial policy and agree to all terms and conditions stated herein.
Patient’s Name:
Responsible
Party
(if
not
the
patient):
HIPAA
Form
Vancouver Spinal Care
1610 C Street Suit 103
Vancouver, Wa 98663
Phone 360.694.0300-Fax 360.694.0301
HIPAA - Notice of privacy
practices
In accordance with The Health Information Privacy and Accountability Act (HIPAA), all healthcare
providers are required by law to maintain the privacy of your health information and provide you a
description of their privacy practices. This notice identifies your rights regarding the center's use of
your protected Health Information. This notice also describes how your health information may be
used and disclosed, and how you can get access to this information.
Each time you visit Vancouver Spinal Care a record of your visit is made. The clinic will use and
disclose health information about treatment and services you receive so that we can bill and receive
payment. We will also tell your insurance company about treatment you are going to receive to
determine whether your plan will cover it.
Information about your treatment and services may also be disclosed to your attorney if an
attorney is involved in litigation regarding the medical necessity of medical massage and the
liability of payment.
Although your health record it the physical property of Vancouver Spinal Care, you have the
right to inspect and upon written request, obtain a copy for a fee of your health information
which usually includes prescriptions and medical and billing records.
If you believe that health information we have about you is incorrect or incomplete, you may
request in writing that we amend your health information.
Our disclosure of your health information is limited to your insurance company, your attorney,
your treating physicians, and you. If the patient is a minor or has a legal guardian, a
parent or guardian is required to read this notice and sign for the patient, and the patient
health information will be disclosed to the parents or guardian.
If you believe your privacy rights have been violated, you may file a written complaint to the
office of civil Rights in the U.S. Department of Health and Human Services at 200 Independence
Avenue SW., Room 509 F, HHH Building, Washington D.C. 20201.
By signing this form you hereby acknowledge that Vancouver Spinal Care may release your
Protected Health Information to carry out payment and treatment operations.
I have read and understand the Notice of Privacy Practices of Vancouver Spinal Care.
_______________________________________________
Date:_______________________
Patient/Patient Representative Signature
