Gary E. Lee, D.C.
6216 South Redwood Road, Salt Lake City UT 84123
Name Today’s date
Date of Accident Time of Accident
Marital status: r Married r Single r Widowed r Divorced Habits: r Smoke r Alcohol
Employment type r Office/clerical r Light labor r Moderate labor r Heavy labor
Past medical history:
Surgeries (dates and residuals) Fractures (dates and residuals) Serious illness (dates and residuals) Workers’ comp. injuries (date, TX, awards, residuals):
Prior Auto Accident/Injuries (date, TX, residuals)
Sports or other injuries to head, neck, or back.
Any prior history of current complaints:
Prior treatment for these:
Was the crash on-the-job? r Yes r No
You were: r Driver r Front seat passenger r Rear seat passenger r Motorcycle operator r Motorcycle passenger r Other
Vehicle driven by:
Your vehicle: Year: Make: Model:
Your estimated speed at moment of crash: MPH
Were you: r Stopped r Slowing r Accelerating
Other vehicle: Year: Make: Model:
They were: r Stopped r Slowing r Accelerating
Time of day: r Daylight r Dawn r Dusk r Dark
Road conditions: r Dry r Damp r Wet r Snow r Ice r Other Headrests r Integral type r Adjustable type: r Up r Down r Don’t know If adjustable, was the position altered by the crash? r Yes r No
Lap belt: r Wearing r Not wearing r Don’t Know
Shoulder Belt: r None r Wearing r Not wearing r Don’t Know Did the Air Bag deploy? r Yes r No
If yes, were you struck? r Yes r No Where? Body position: Good Forward lean Other
Head position: Forward Left ° Right ° Up ° Down ° Hands: r One on wheel r Two on wheel r N/A
Were your brakes applied? r Yes r No
Were you aware of impending crash? r Yes r No
During the crash:
Did you strike any parts of the vehicle? r Yes r No If yes, describe
Did vehicle strike any objects after crash? r Yes r No If yes, describe:
Wearing hat or glasses? r Yes r No If yes, still on after crash? r Yes r No Did you lose consciousness? r Yes r No If yes, for how long?
Estimated property damage to your vehicle? r None r Minimum r Moderate r Major Estimated damage to other vehicle(s) r None r Minimum r Moderate r Major Were the police on-scene? r Yes r No
If yes, was a report made? r Yes r No City:
After the crash:
Symptoms: r Headache r Dizziness r Nausea r Confusion/disorientation r Neck pain r Numbness r Tingling r Weakness
r Arm pain r Leg pain r Hand pain r Foot pain Other, please explain:
When did SX first appear? Immediately(describe which SX: Later that day:
Where did you go after the crash?
r Home r Work r Hospital r Private doctor Name of Hospital or Doctor
Mode of transportation r Ambulance r Other: Emergency department:
Were X-rays taken? Yes No
Body parts imaged? r MRI r CT Scan r Other: Results:
Lab work r Yes r No r
Treatment Offered r Cervical collar r Ice r Medications: Follow-up instructions
Please indicate the areas of discomfort or pain that you are experiencing:
Additional information you would like the Doctor to know:
AND INSTRUCTIONS TO COUNSEL
I, the undersigned, understand that all past, present and future bills incurred at the Doctor/Clinic noted below, are my responsibility for payment. I hereby ratify my agreement to pay all bills incurred during my health care at this Clinic.
In consideration for the below named Doctor/Clinic having agreed to treat me without payment at the time of service and enabling me to obtain treatment for my accident/injury/Illness, without financial hardship, I give you a lien on any settlement, clear judgment, verdict or result of accident/injury/illness and I agree to irrevocably instruct my attorney to pay you in full from any proceeds of settlements, claim or judgment related to this accident/ injury/illness.
I also understand that if the settlement does not cover my entire bill at this Clinic, I am still responsible for the remainder and the payment by me of this bill is not contingent on any settlement, claim or judgment which I may eventually recover.
Furthermore in consideration for the below named Doctor/Clinic refraining from attempting to collect immediate payment for services rendered for my accident/injury/illness, I do herby waive and toll any applicable status of limitations on the collection of my account until I notify the Doctor/Clinic of the conclusion of my efforts to obtain a settlement or judgment through the assistance of my attorney and for a period of three (3) months thereafter.
_____________________________________ Patient Name (Please Print)
________________________________________ Patient Signature ________________________________________ Date Gary E. Lee, D.C. 4091 S. Redwood Road Salt Lake City, UT 84123
INSTRUCTIONS TO COUNSEL
I do herby irrevocably instruct you, my Attorney, named below, to pay Doctor/Clinic named above in full for services to me for my client/Injury/Illness from any proceed or settlement, claim or judgment regarding accident/ injury/illness. You are to pay the Doctor/Clinic prior to distributing any proceeds to me and I instruct you not to attempt to reduce my doctor's bill by means of negotiation for the services that have been provided to me for the accident/Injury/Illness which I have agreed to pay in full.
Gary E. Lee, D.C. 6216 S. Redwood Road Salt Lake City, Utah 84123
Name: Age: Address:
City/State/Zip Home Phone: Work Phone: Cell Phone: Date of Birth Circle one: Single Married
Employer Name: Employer Address
Spouse’s Name Spouse’s Telephone # Emergency Contact Name Emergency Contact Phone
How did you hear about our clinic?
Insurance Company Name: Address:
Insurance Phone: Policy Number:
Insured’s Name Relationship to the insured: Attorney Name Attorney Phone
I hereby authorize Dr. Gary Lee, D.C. to take any and all necessary x-rays of myself or my minor child and any necessary treatment.
_____________________________ ______________________ Patient Signature Date
I affirm that the above information is current and correct to the best of my knowledge. I have read and understand the terms of the chiropractic treatment. It is my responsibility to inform Dr. Lee of any change of address, phone number, employer, or insurance information or new accident or injury. I accept responsibility for the account and any charges related to my treatment regardless of whether or not the insurance pays. My signature assigns insurance benefits to Dr. Gary Lee and/or Optimum Spine and Health Clinics, P.C. and gives permission to share information with my insurance company in order to process the claims.
_____________________________________ _____________________ Signature of Patient/Parent/Guardian Date
Consent for Use and Disclosure of Health Information
Our Privacy Pledge
We are very concerned with the protection of your privacy. While the law requires us to give you this disclosure, please understand that we have, and always will respect the privacy of your health information. There are several circumstances in which we may have to use or disclose your health care information.
1. We may have to disclose your health care information to another health care provider or to a hospital if it is necessary to refer you to them for a diagnosis, assessment, or treatment.
2. We may have to disclose your health care information and billing records to another party if they are potentially responsible for the payment of your services. Your signature gives permission to provide this information via telephone, fax, or e-mail.
3. We may need to use your health information within our practice for quality control or other operational purposes.
4. We may need to use your personal information to remind you of your appointments, send you a birthday card, send you a thank you for referrals, acknowledge your referral on an in office referral board, send you a welcome to the office information letter, invite you to participate in patient appreciation days, send you an office newsletter, or send promotional information.
We have a more complete notice that provides a detailed description of how your heath information may be used or disclosed. You have the right to view that notice before you sign this consent form.
We reserve the right to change your privacy practices as described in that notice. If we make any change to your privacy practices, we will notify you in writing when you come in for treatment or by mail. Please feel free to call us at any time for a copy of our privacy notices.
You’re right to limit uses or disclosures.
You have the right to request that we do not disclose your health information to specific individuals,
companies, or organizations. If you would like to place any restrictions on the use or disclosure of your health information, please let us know in writing. We are not required to agree to your restrictions. However, if we agree with your restrictions, the restriction is binding upon us.
You’re right to revoke your authorization.
You may revoke your consent to us at any time; however, your revocation must be in writing. We will not be able to honor your revocation request if we have already released your health information before we receive your request to revoke your authorization. If you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to you health information if they decide to contest to any of your claims.
I have read your consent policy and agree to its terms. I am also acknowledging that I have received a copy of this notice.
_______________________________ _______________________________________ Print Name Authorized Provider Representative