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C-258 (6-95) NS

Application for Benefits – Personal Injury Protection

To enable us to determine if you are entitled to benefits under the __________________ Personal Injury Protection Law (and/or No-Fault Law), please complete this form and return in promptly.

To:

Claims Department

YOUR NAME: HOME PHONE BUSINESS PHONE

ADDRESS (NO., STREET, CITY/TOWN, STATE AND ZIP CODE) DOB SS#

PERMANMENT ADDRESS, IF DIFFERENT – HOW LONG HAVE YOU LIVED AT THAT ADDRESS?

DATE & TIME OF ACCIDENT PLACE OF ACCIDENT (STREET, CITY/TOWN AND STATE)

BRIEF DESCRIPTION OF ACCIDENT AND VEHICLES INVOLVED:

AT TIME OF ACCIDENT: Were you the driver of our policyholder’s car? YES OR NO

Were you a passenger in our policyholder’s car? YES OR NO

Were you a pedestrian? YES OR NO

Are you a member of our policyholder’s household? YES OR NO IF yes, what is your relationship?

AS A RESULT OF THIS ACCIDENT WERE YOU INJURED? YES OR NO IF YOUR ANSWER IS YES,

COMPLETE THE REST OF THIS FORM. IF NO, SIGH HERE AND RETURN THIS FORM TO US.

SIGNATURE: DATE:

DESCRIBE YOUR INJURY

HAVE YOU EVER HAD SAME OR SIMILAR CONDITIONS: YES OR NO IF “YES”, STATE WHEN AND

DESCRIBE:

IS CONDITION SOLELY A RESULT OF THIS ACCIDENT? YES OR NO IT “NO”, EXPLAIN:

WERE YOU TREATED BY A DOCTOR? DOCTOR’S NAME AND ADDRESS

YES OR NO

IF YOU WERE TREATED IN A HOSPITAL, WERE YOU… AN IMPATIENT OR AN OUTPATIENT

HOSPITAL’S NAME AND ADDRESS

AMOUNT OF MEDICAL BILLS TO DATE WILL YOU HAVE MORE MEDICAL EXPENSES?

AT THE TIME OF YOUR ACCIDENT, WERE YOU IN THE COURSE OF YOUR EMPLOYMENT?

(2)

Date Insurance Co.

Patient ID# Group #:

Address Address

City/State/Zip: City/State/Zip:

Sex: M F Age Birthdate Your SS#

Single Married Widowed Separated Divorced Relationship to subscriber:

Driver's License # Subscriber's Name

Email Subscriber's Birthdate

Would you like to receive our Health Newsletter Yes No Subscriber's SS#

Occupation Is patient covered by additional insurance? Yes No

Employer Insurance Co.

Employer Address ID #: Group #:

Employer Phone ext. Customer Service Phone #

Spouse's Name ASSIGNMENT AND RELEASE

Spouse's Birthdate SS#

Spouse's Occupation Spouse's Employer

Whom may we thank for referring you?

Relationship Date

Cell Home Is condition due to an accident? Yes No Date

Best time and place to reach you Type of accident: Auto Work Home Other:

IN CASE OF EMERGENCY, CONTACT To whom have you made a report of your accident?

Name Relationship Auto Insurance Employer Worker Comp. Other:

Home Phone Cell Phone Attorney Name (if applicable)

Reason for visit

When did your symptoms appear?

Is this condition getting progressively worse?

Where do you continue to have pain, numbness, or tingling?

Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain)

Type of pain: Sharp Dull Throbbing Numbness Aching Swelling Burning Tingling Cramps Stiffness Swelling Other:

How often do you have this pain? Is it constant or does it come and go?

Does it interfere with your Work Sleep Daily Routine Recreation

Activities or movements that are painful to perform: Sitting Standing Walking Bending Lying down

*Namasté Integrative Medicine - 5331 NW Macadam Ave. Suite #307 - Portland, OR 97239 (503) 226-8010*

CHIROPRACTIC REGISTRATION AND HISTORY

PATIENT INFORMATION INSURANCE

PHONE NUMBERS ACCIDENT INFORMATION (circle each that applies) Responsible Party Signature

PATIENT INFORMATION

I, the undersigned certify that I (or my dependent) have insurance coverage with___________________________and assign directly to Dr. Allen Knecht all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

(3)

! " # $ % & " ' ( % % $ ) " * + ' , * - . / 0 1 + $ . * '

P a t i e n t I n f o r m a t i o n

Today’s date: Patient Name:

Date of Accident: Time of Accident a.m.

p.m. Please describe the accident in your own words:

Were you the: !Driver !Front Passenger !Rear Passenger !Pedestrian

How many people were in the accident vehicle? ACCIDENT SITE

Road/Street Name City/State

Nearest intersection with road/street:

Driving Conditions: ☐Dry ☐Wet ☐Icy ☐Other Which directions were you headed?

Speed you were traveling? VEHICLE

Make and model of the vehicle you were in: Where you wearing a seatbelt? ☐Yes ☐No If yes, what type? ☐Lap ☐Shoulders

Was the vehicle equipped with airbags? ☐Yes ☐No If yes, did it/they inflate properly? ☐Yes ☐No Did your seat have a headrest? ☐Yes ☐No If yes, what was the position of the headrest? ☐Low ☐Mid-position ☐High

OTHER VEHICLE (if applicable) Make and model of the other vehicle:

Which direction was the other vehicle headed: Speed the other vehicle was traveling?

IMPACT

Did your car impact another vehicle? ☐Yes ☐No Did your car impact a structure? ☐Yes ☐No If yes, explain

Did any part of your body strike anything in the vehicle? ☐Yes !No If yes, explain:

You were impacted from:

☐Front ☐Rear ☐Left ☐Right ☐Other At the time of the impact, were you:

☐Looking straight-ahead ☐Looking to the right ☐Looking to the left ☐Looking down

☐Looking up

Were both hands on the steering wheel? ☐Yes ☐No If no, which hand was which hand was on the wheel? ☐Right ☐Left

Was your foot on the break? ☐Yes ☐No Were you: ☐Surprised by the impact ☐ Braced for the impact

POLICE

Did the police come to the accident site: ☐Yes ☐No Were there any witnesses? ☐Yes ☐No

Was a police report filed? ☐Yes ☐No Was a traffic violation issued? ☐Yes ☐No If yes, to whom?

(4)

PATIENT CONDITION

Were you unconscious immediately after the accident? ☐Yes ☐No If yes, for how long? Please describe how you felt immediately after the accident:

TREATMENT Did you go to the hospital? !Yes !No

When did you go? !Immediately after the accident ☐Next day ☐2 days or more after the accident How did you get to the hospital? !Ambulance !Private transportation

Name of hospital: Diagnosis:

Treatment received: X-Rays taken:

SYMPTOMS/INJURIES

Have you been able to work since this injury? !Yes !No How many days of work have you missed? Prior to the injury were you able to work on an equal basis with others your age?

If you have had any of the following symptoms since your injury, please check:

!Arm/shoulder pain !Fee/toe numbness !Neck pain

!Back pain !Hand/finger numbness !Neck stiff

!Back stiffness !Headaches !Shortness of breath

!Chest pain !Irritability !Sleep difficulty

!Dizziness !Jaw problems !Stomach upset

!Ear buzzing !Leg pain !Tension

!Ear ringing !Memory loss !Vision blurred

!Fatigue !Nausea

Is this condition getting progressively worse? !Yes !No !Unknown

Where do you continue to have pain, numbness, or tingling?

Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain) Type of pain:

!Sharp !Dull !Throbbing !Numbness

!Aching !Shooting !Burning !Tingling

!Cramps !Stiffness !Swelling !Other

Is this condition getting progressively worse? !Yes !No !Unknown Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain): How often do you have pain?

Is it constant or does it come and go?

Does it interfere with your: !Work !Sleep !Daily Routine !Recreation

Activities or movements that are painful to perform: !Sitting !Bending !Standing !Lying down !Walking I certify that the above information is correct to the best of my knowledge.

(5)

Namasté Integrative Medicine

Allen Knecht, D.C.

5331 SW Macadam Ave. Ste #307

Ben Narcisi, D.C.

Portland, OR 97239

P(503) 226-8010 - F(503) 210-0338

Auto
Accident
Injuries


Patient’s
Bill
of
Rights


After
you
have
been
injured
in
an
Auto
Accident:


Report
the
accident
to
the
Auto
Insurance
covering
the
car
you
were
in
at
that
time
of
the
accident.


1. If
you
were
the
driver:
report
the
accident
to
your
insurance
company.


2. If
you
were
a
passenger:

make
sure
that
the
car’s
owner
has
reported
the
accident
to
their


insurance
company
and
has
mentioned
that
you
were
a
passenger
who
may
have
been
injured.


After
the
accident
has
been
reported,
the
insurance
company
will
send
you
a
form,
which
is
called
the


Personal
Injury
Protection
(PIP)
Application
for
benefits.


1. Fill
out
this
form
and
send
it
back
to
the
insurance
company
ASAP.

Your
signed
PIP


application
releases
the
insurance
company
to
start
paying
your
medical
bills.


2. If
you
do
not
fill
out
and
return
the
PIP
form
to
the
insurance
company,
the
medical
bills


will
become
your
responsibility
by
default.


3. Make
a
copy
of
the
PIP
application
for
your
records.

The
treating
doctor
will
also
require
a


copy
of
the
PIP
application.



Standard
procedure
in
this
clinic
is
to
bill
YOUR
Auto
Insurance
(or
the
auto
insurance
company
of
the


owner
of
the
car
you
were
in)
for
services
rendered
at
this
clinic.

This
will
ensure
that
medical
bills
are


paid
as
you
are
treated.

This
is
standard
procedure
in
the
state
of
Oregon
even
if
you
were
NOT
at
fault.


If
the
car
in
which
you
were
riding
was
uninsured
at
the
time
of
the
accident,
please
discuss
the


particulars
with
our
staff.

We
will
help
you
determine
if
a
third
party
insurance
benefit
is
available.


If
you
choose
not
to
use
you
PIP
medical
coverage,
we
expect
payment
at
time
of
service.


Every
insurance
company
has
the
right
to
have
any
patient
examined
by
a
physician
of
their
choice.

This


is
called
an
Independent
Medical
Exam
(IME).

Please
inform
the
Namasté
staff
if
your
insurance


company
has
scheduled
you
for
an
IME.


Any
communication
received
from
the
insurance
company
via
phone
or
letter
should
be
conveyed
to


your
treating
physician.

Always
get
the
name
of
the
insurance
representative
with
whom
you
have
been


talking
to.


The
insurance
company
of
the
car
that
hit
you
normally
pays
the
repair
or
replacement
of
your
vehicle.



If
the
other
driver
was
uninsured
or
you
are
considered
at
fault,
your
company
may
be
looked
to
for
car


repairs.


After
you
are
medically
stationary
(no
further
improvement
expected
with
time
or
treatment)
you
may


be
approached
by
the
at
fault
driver’s
insurance
company
about
a
settlement.

When
a
settlement
is


reached,
your
company
is
paid
back
for
your
medical
bills
they
paid
out.

You
may
also
be
eligible
for
a


pain
and
suffering
cash
payment
also.

You
can
reach
a
settlement
on
your
own
or
with
an
attorney’s


help.
 


(6)

IRREVOCABLE DOCTOR’S LIEN AND ASSIGNMENT OR RIGHT TO RECOVERY

In consideration and exchange for not having to immediately pay a debt owed and in consideration for receiving future care at or by the clinic and doctors on whose letterhead this document is printed (hereinafter “Clinic”), I, the undersigned, hereby assign and convey to the Clinic a legal and all causes of action or rights of recovery I may have arising out of that certain accident or injury-producing event which occurred on or about the __________day of _________________, 20____, to the full extent of the cost and treatment provided to me by the Clinic.

I hereby authorize and direct my attorney(s) to hold in trust, and to pay directly to the Clinic such sums as may be due and owing the Clinic for treatment and other professionals services rendered me both by reason of this accident and by reason of any other bills that are due the Clinic and to withhold such sums from any settlement, judgment or verdict as may be necessary to adequately pay and protect the Clinic. I hereby further give, grant, and convey a lien on my case to the Clinic against any and all proceeds of any and all causes of action, settlements, judgments or verdicts which may be paid to or through my attorney, or myself, as the result of the injuries or conditions from which I have been treated by the Clinic.

I fully understand that I am directly and fully responsible to the Clinic for all bills incurred for services rendered me and that this agreement is made solely for the Clinic’s additional protection and in consideration for the Clinic’s waiting for payment. I further understand that payment for services rendered by the Clinic is not contingent on any settlement, judgment, or verdict by which I may eventually recover. I am personally responsible for my bills, regardless of the outcome of any legal claim or case.

I fully understand that if my attorney(s) does/do not protect the Clinic’s interest, the Clinic may require me to make payments on a current basis. The Clinic may also bring a cause of action against my attorney(s) for failing to honor this binding and irrevocable assignment between me and the Clinic.

“I HAVE READ AND FULLY UNDERSTAND THIS DOCUMENT, AND I AM VOLUNTARILY SIGNING THIS DOCUMENT. I AM DIRECTING MY ATTORNEY(S) TO PROTECT THE CLINIC’S AND DOCTOR’S INTEREST AT THIS TIME OF SETTLEMENT, AND I AM ASSIGNING AND CONVEYING CERTAIN LEGAL RIGHTS OVER TO THE CLINIC. I ALSO KNOW I MAY NOT REVOKE THIS AGREEMENT AT ANY TIME WITHOUT PRIOR WRITTEN AUTHORIZATION FROM THE CLINIC. I UNDERSTAND THAT, AMONG OTHER THINGS, THIS IS A BINDING AND ENFORCEABLE CONTRACT, ASSIGNMENT, AND LIEN.”

_____________________________________ _____________________________ _________________________

Patient Name (Print) Patient Signature Date

A copy of this shall serve as original

Namasté Integrative Medicine

5331 SW Macadam Ave. Suite #307

Portland, OR 97239

(7)

Namasté Integrative Medicine – 5331 SW Macadam Ave Suite #307 – Portland, OR 97239 (503) 226-8010

The Rivermead Post Concussion Symptoms Questionnaire

After a head injury or accident some people experience symptoms, which can cause worry or nuisance. We would to know if you now suffer any of the symptoms given below. As many of these symptoms occur normally, we would like you to compare yourself now with before the accident. For each one please circle the number closest to your answer.

0= not experienced at all

1= no more of a problem now than before the accident 2= a mild problem now

3= a moderate problem now 4= a severe problem now

Compare with before the accident, do you now (i.e. over the last week) suffer from:

Headaches 0 1 2 3 4

Feelings of dizziness 0 1 2 3 4

Nausea and/or vomiting 0 1 2 3 4

Noise sensitivity, or easily upset by loud noise 0 1 2 3 4

Sleep disturbance 0 1 2 3 4

Fatigue, tiring more easily 0 1 2 3 4

Being irritable, easily angered 0 1 2 3 4

Feeling depressed or tearful 0 1 2 3 4

Feeling frustrated or impatient 0 1 2 3 4

Forgetfulness, poor memory 0 1 2 3 4

Poor concentration 0 1 2 3 4

Taking longer to think 0 1 2 3 4

Blurred vision 0 1 2 3 4

Light sensitivity, or easily upset or irritated by bright light 0 1 2 3 4

Double vision 0 1 2 3 4

Restlessness 0 1 2 3 4

Are you experiencing any other difficulties? Some other symptoms of Post Concussion Syndrome include the following: Reading problems, writing problems (writing the wrong letter first), typing problems, inability to remember ATM or other numbers, attention impairment, personality changes, intolerance to heat, intolerance to cold, intolerance to alcohol, and loss of sex drive/libido. Please specify any of theses additional problems you experience, and rate as above.

1. 0 1 2 3 4

2. 0 1 2 3 4

3. 0 1 2 3 4

4 0 1 2 3 4

Patient Name: Date:

King NS, Crawford S, Wenden FJ, Moss NEG, Wade DT. (1995) The Rivermead Post Concussion Symptoms Questionnaire: a measure of symptoms commonly experienced after head injury and its reliability. JNeurol242 : 5587-592

(8)

C-258 (6-95) NS

DID YOU LOSE WAGES OF SALARY AS A RESULT OF YOUR INJURY? YES OR NO

IF YES, AMOUNT LOST TO DATE: $

WHAT IS YOUR AVERAGE WEEKLY OR SALARY? $

IF YOU LOST WAGES: DATE DISABILITY FROM WORK BEGAN:

DATE YOU RETURNED FROM WORK: HAVE YOU RECEIVED OR ARE YOU ELIGIBLE FOR BENEFITS UNDER:

ANY WORKER’S COMPENSATION LAW? YES OR NO

EMPLOYMENT BY U.S. GOVERNMENT? YES OR NO

MILITARY SERVICE? YES OR NO

LIST NAMES AND ADDRESSES OF YOUR PRESENT EMPLOYERS AN GIVE YOUR OCCUPATION AND DATES O EMPLOYMENT FOR EACH:

EMPLOYER AND ADDRESS YOUR OCCUPATION FROM TO

EMPLOYER AND ADDRESS YOUR OCCUPATION FROM TO

AS A RESULT OF YOUR INJURY HAVE YOU HAD ANY OTHER EXPENSES? YES OR NO

IF “YES”, EXPLAIN:

SIGNATURE: DATE:

IMPORTANT:

1. TO BE ELIGIBLE FOR BENEFITS, COMPLETE AND SIGN THIS APPLCATION. 2. SIGN AUTHORIZATION(S) BELOW.

3. RETURN PROMPTLY WITH ANY MEDICAL BILLS YOU HAVE REVCEIVED TO DATE. *ATTACH ADDITIONAL SHEET IF MORE SPACE IS NEEDED

MEMBER NATIONAL INSURANCE CRIME BUREAU

C-258 (6-95) NS

AUTHORIZATION FOR MEDICAL INFORMATION

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 and physical findings, diagnosis and prognosis. You are authorized to provide this information in accordance with the

Personal Injury Protection Law (and/or No Fault Law).

Signature: Date:

AUTHORIZATION FOR WAGE AND SALARY INFORMATION

This authorization or photocopy hereof will authorize you to furnish all information you may have regarding my wages or salary while employed by you. You are authorized to provide this information in accordance with the

Personal Injury Protection Law (and/or No-fault Law)

(9)

In order to properly assess your condition, we must understand how much your neck and/or low back problems have affected your ability to manage everyday activities. For each item below, please circle which number closely describes your condition

right now.

Patient Name: 1. Pain Intensity

0 1 2 3

No Mild Moderate Severe Worst

Pain Pain Pain Pain Possible

Pain

2. Sleeping

0 1 2 3

No Mild Moderate Severe Worst

Pain Pain Pain Pain Possible

Pain

3. Personal Care (washing dressing, etc.)

0 1 2 3

No Mild Moderate Severe Worst

Pain Pain Pain Pain Possible

Pain

4. Travel (driving, etc.)

0 1 2 3

No Mild Moderate Severe Worst

Pain Pain Pain Pain Possible

Pain

5. Work

0 1 2 3

No Mild Moderate Severe Worst

Pain Pain Pain Pain Possible

Pain

6. Recreation

0 1 2 3

No Mild Moderate Severe Worst

Pain Pain Pain Pain Possible

Pain

7. Frequency of pain

0 1 2 3

No Mild Moderate Severe Worst

Pain Pain Pain Pain Possible

Pain

8. Lifting

0 1 2 3

No Mild Moderate Severe Worst

Pain Pain Pain Pain Possible

Pain

9. Walking

0 1 2 3

No Mild Moderate Severe Worst

Pain Pain Pain Pain Possible

Pain

10. Standing

0 1 2 3

No Mild Moderate Severe Worst

Pain Pain Pain Pain Possible

Pain

Patient Signature: Date:

Functional Rating Index

(10)

Acknowledgement of Receipt of

Notice of Privacy Practices

This form will be retained in your medical record.

NOTICE TO PATIENT

We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information. Please sign this form to acknowledge receipt of the Notice.

Patient Name:

Date of Birth:

I acknowledge that I have received and had the opportunity to review the Notice of Privacy

Practices on the date below on behalf of Namaste Integrative Medicine.

I understand that the Notice describes the uses and disclosures of my protected health

information by Namaste Integrative Medicine and informs me of my rights with respect to my

protected health information.

Patient’s Signature or that of Legal Representative Printed Name of Patient or that of Legal Representative

Today’s Date If Legal Representative, Indicate Relationship

1

Namasté Integrative Medicine

5331 SW Macadam Ave. Suite 307

Portland, OR 97239

(11)

FOR OFFICE USE ONLY

We have made every effort to obtain written acknowledgment of receipt of our Notice of Privacy from this patient but it could not be obtained because:

The patient refused to sign.

Due to an emergency situation it was not possible to obtain an acknowledgement Communications barriers prohibited obtaining the acknowledgement

Other (please specify):

Employee Name Today’s Date

References

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