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