Accident / Injury Report
Name ______________________________Date_______________ Date of birth__________________ Date of accident________________________ Time of accident _________________________am / pm. Auto injury
Were you: ___ Driver ___Passenger ___Pedestrian
Were you struck from: __ Behind __ Right Side __Left Side __Front __ Parked? Did your car strike the others involved: ___Yes___ No___ Undetermined
Did the other car strike yours: ___Yes___ No ___ Undetermined
As a result of the Accident, were traffic citations issued to you? ___Yes ___ No Other injury
Describe the circumstances of the accident (be specific): _______________________________________ Check symptoms you have noticed since the accident:
__Headache __Ears Ringing __Neck Pain __Face Flushed __Neck Stiff __Dizziness __Back Pain __Nervousness __Tension __Irritability __ Chest Pain __Sleeping Problems __Buzzing in Ears __Loss of Balance __ Fainting __Loss of Smell __Loss of Taste __Diarrhea __Feet Cold __ Hands Cold __Stomach Upset __ Constipation __Cold Sweats __Fever
__Fatigue __Depression __Lights Bother Eyes __Loss of Memory __Head Too Heavy __Pins & Needles in Arms __Pins & Needles in Legs
__Numbness in Fingers __Numbness in Toes __Shortness of Breath
Insurance information
Your Insurance Company: _________________________Address:_______________________________ Other Party’s Name: _____________________________Address:_______________________________ Other Party’s Ins. Co: _____________________________ Address: _______________________________ Have you been contacted by an insurance adjustor regarding this claim? __Yes __ No
If yes, adjustor’s name: ___________________________ Address: _______________________________ Phone: _________________Fax:________________________ Claim number: ______________________ Do you have an attorney that has advised you in this case: __Yes __ No
If yes, attorney’s name ____________________________Address:_______________________________ I attest that all of the above information on this form is correct to the best of my knowledge.
____________________________________________________________________________________
Signature Print Name Date
Assignment of Benefits:
Assignment of Cause of Action: Contractual Lien
The undersigned patient or responsible party, in addition to continuing personal responsibility, and in consideration of treatment rendered or to be rendered assigns to Mia D. Frails, D.C., the following rights, power and authority:
RELEASE OF INFORMATION: You are authorized to release information concerning my condition and
treatment to my insurance company, attorney, or insurance adjuster for purposes of processing my claim for benefits and payment of services rendered to me.
IRREVOCABLE ASSIGNMENT OF RIGHTS: You are assigned the exclusive, irrevocable right to any cause
of action that exists in my favor against any insurance company for the terms of the policy, including the exclusive, irrevocable right to receive payment for such services makes demand in my name for payment, and prosecute and receive penalties, interest, court loss, or other legally compensable amounts owned by an insurance company, provide information as needed, and appear as needed, wherever to assist in the prosecution of such claims for benefits upon request.
DEMAND FOR PAYMENT: To any insurance company providing benefits of any kind to me/us for
treatment rendered by Mia D. Frails, D.C./Back to Life Health & Wellness, you are hereby tendered demand to pay in full the bill for services rendered by Mia D. Frails, D.C./Back to Life Health & Wellness Within 30 days following your receipt of such bill for services to the extent such bills are payable under the terms of the policy. I further instruct the provider to make all checks payable to Back to Life Health & Wellness, and to send all checks to 1916 Patterson St. Ste. 606, Nashville, TN 37203.
THIRD PARTY LIABILITY: If my injuries are the result of negligence from a third party, then I instruct the
Liability carrier to cut a separate draft to pay in full all services rendered, payable directly to Back to Life Health & Wellness, and to send all checks to 1916 Patterson St. Ste. 606, Nashville, TN 37203.
page continued from previous page STATUTE OF LIMITATIONS: I waive my rights to claim any statute of limitations regarding claims for
services rendered or to be rendered by Mia D. Frails, D.C./Back to Life Health & Wellness, in addition to reasonable cost of collection, including attorney fees and court cost uncured.
LIMITED POWER OF ATTORNEY: I hereby grant to Mia D. Frails, D.C./Back to Life Health & Wellness the
power to endorse my name upon any checks, drafts, or other negotiable instrument representing payment from any insurance company representing payment for treatment and healthcare rendered by Mia D. Frails, D.C./Back to Life Health & Wellness. I agree that any insurance payment representing an amount in excess of the charges for treatment rendered will be credited to my/our account or forwarded to my/our address upon request in writing to Mia D. Frails, D.C./Back to Life Health & Wellness.
REJECTION IN WRITING: I hereby authorize Mia D. Frails, D.C./Back to Life Health & Wellness to establish a PIP or
UM claim on my behalf. I also instruct my insurance carrier to provide upon request to the provider/facility named above, any rejections in writing as they apply to my lack of PIP or UM/UIM coverage. I further instruct my carrier to pay up to available limits directly to physician/facility named above, and to send any and all checks or financial instruments to Back to Life Health & Wellness 1916 Patterson St. Ste. 606, Nashville, TN 37203.
TERMINATION OF CARE: I hereby acknowledge and understand that if I do not keep appointments as
recommended to me by my caring doctor at Back to Life Health & Wellness, he/she has full and complete right to terminate responsibility for my care and relinquish any disability granted me within a reasonable
period of time. If during the course of my care, my insurance company requires me to take an examination from any other doctor; I will notify this physician/facility immediately. I understand that failure to do so may jeopardize my case.
______________________________________________________________________________
PATIENT SIGNATURE PRINT NAME DATE
______________________________________________________________________________
WITNESS SIGNATURE PRINT NAME DATE
Patient History (page 1 of 2)
Name________________________________ Referred by _________________________________ Date ____________________ Social Security # _________________________________
Address _________________________________________ Occupation ______________________ City____________________, State_________, Zip_____________ Employer_______________________ Phone (c) __________________ (w) ______________________ Marital Status __s __m __d __w
E-mail _____________________________________ Spouse’s Name__________________________ Date of Birth ______________ (age) _____ Spouse’s Date of Birth______________________ Family Medical Doctor: ______________________When doctor’s work together it benefits you.
May we have your permission to update your medical doctor regarding your care at this office? __Yes__ No
Children Previous Chiropractic Care?
Name __________________Age _______Yes______ No_____ Reason____________________________ Name __________________Age _______Yes______ No_____ Reason____________________________ Name __________________Age _______Yes______ No_____ Reason____________________________ Name __________________Age _______Yes______ No_____ Reason____________________________
Health Insurance
Please check any and all insurance coverage that may be applicable in this case: __ Major Medical __Medicaid __Medicare__ Auto Accident __Workers Compensation
__Medical Savings Account & Flex Plans __Other________________________________________ Please provide us with your insurance card when you submit your patient history form.
Authorization and release
I authorize payment of insurance benefits directly to the chiropractor or chiropractic office. I authorize the doctor to release all information necessary to communicate with personal physicians and other health care providers and payers and to secure the payment of benefits. I understand that I am responsible for all costs of chiropractic care, regardless of insurance coverage. I also understand that if I suspend or terminate my schedule of care as
determined by my treating doctor, any fees for professional services will be immediately due and payable. The patient understands and agrees to allow this chiropractic office to use their Patient Health Information for the purpose of treatment, payment, health care operations, and coordination of care. We want you to know how your Patient Health Information is going to be used in this office and your rights concerning those records. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent. The following person(s) have my permission to receive my personal health information:
I attest that all of the above and following information on this form is correct to the best of my knowledge. ____________________________________________________________________________________
Patient’s Signature: Date:
Patient History (page 2 of 2)
Circle all that apply
Patient
Spouse
Child 1
Child 2
Child 3
Did or do you...
Smoke? Y Y Y Y Y
Drink? Y Y Y Y Y
Diet (do you eat healthy foods?) Y Y Y Y Y Drugs? (Prescriptive or non-prescriptive) Y Y Y Y Y
Exercise regularly? Y Y Y Y Y
Have occupational stress? Y Y Y Y Y
Have physical stress? Y Y Y Y Y
Have mental stress? Y Y Y Y Y
Have accident, work, or sports injuries? Y Y Y Y Y
Current health Condition
Briefly tell us the reason for your visit today: ______________________________________________ Pain or Problem started on __________________ Pain is: ___Sharp___ Dull__ Constant__ Intermittent What activities aggravate your condition/pain? ____________________________________________ What activities lessen your condition/pain? _______________________________________________ Is condition worse during certain times of the day? __________________________________________ Is this condition interfering with __Work? __ Sleep? __Other: Is it getting worse? __Yes __No
Other Doctors seen for this condition _____________________________________________________ Any home remedies? _____________________________ Are you currently pregnant? ___Yes___ No
Other symptoms
__Headaches __Neck pain __Sleeping problems __Back pain __ Nervousness __Tension __Irritability __Chest pains
__Dizziness __Face flushed __Neck stiff __ Pins & needles in legs __ Pins & needles in arms __ Numbness in fingers __Numbness in toes Shortness of breath
__ Fatigue __ Depression __Light bothers eyes __Loss of memory __ Ears ring __Fever __Fainting __Buzzing in ear __Loss of smell __Loss of taste __Diarrhea __Feet cold __ Hands cold __Stomach upset __ Constipation __Loss of balance
Are you currently under drug and medical care? ___________________________________________________ What medications are you taking? __________________________ How Long? __________________________ Have you had surgery? __Yes__ No What? _____________________ When? _____________________________ What side effects have you experienced from the drugs and surgery? ____________________________________ History of Heart Disease Stroke Arthritis Cancer Diabetes Other
Mother’s Side Y Y Y Y Y ______________ Fathers Side Y Y Y Y Y ______________ As a result of my chiropractic care, I would like to (check all that apply)
___Feel better quickly ___Have a healthier spine ___ Have a healthier body by keeping my nerve system healthy ___Live a healthier lifestyle
