MVA Accident Questionnaire

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2225 Vatican Lane Dallas, TX 75224 214-333-3393 FAX: 214-333-0809

4230 W Green Oaks Blvd Arlington, TX 76016 817-200-7533 FAX: 8117-476-6051

Dr. Louis Zegarelli

Name ____________________ Date _

Date of Accident ___________ Time of Accident _

Road conditions at time of accident ________________________________________________

Were you the driver? YES NO Were you the passenger? YES NO

Where were you seated in the vehicle? FRONT BACK LEFT RIGHT Were you transported by Ambulance? YES NO

Were you seen in the Emergency Room? YES NO Were you admitted to the Hospital? YES NO Were X-rays or an MRI done? YES NO

Patient Car Year Make Model Speed

Other Car Year _______ Make Model_ Speed ______

Please draw your accident

Please describe your accident

______________________________________________________________________

Describe your injury (injuries)

______________________________________________________________________

MVA Accident Questionnaire

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PLEASE PRINT CLEARLY

Name _______________________________________________

If married, Maiden Name _______________________________

Social Security # ______________________________________

Date of Birth month __________ day __________ year ______

Marital Status (circle one) married single domestic partner Gender male female Race __________________

Ethnicity _____________ Languages spoken ______________

Home address ________________________________________

City _______________ State ________ Zip_________

Mailing Address (if different) ____________________________

City________________ State ________ Zip ________

Home Phone (_______) _______________________________

Mobile Phone (_______) _______________________________

Work Phone (_______) _______________________________

Personal email _______________________________________

Pharmacy ____________________________________________

Phone ________________________________________

Who referred you to Dr. Zegarelli?

_____________________________________________

Responsible Party on this account self other _____________

If Other: Name ________________________________

Relationship to Patient __________________________

Mailing Address _______________________________

City _______________ State ________ Zip _________

Phone (________) ______________________________

Email ________________________________________

Emergency Contact responsible party other

If Other: Name ________________________________

Relationship to Patient __________________________

Mailing Address _______________________________

City _______________ State ________ Zip _________

Phone (________) ______________________________

Email ________________________________________

Kiest Park Medical Clinic

Smart Living Medical Center

Dr. Louis Zegarelli

Primary Insurance Co. __________________________________

Plan Name ___________________________________________

Plan Type ____________________________________________

Group Name _________________________________________

Group # _____________________________________________

Policy # (ID #) ________________________________________

Start/Effective Date ___________________________________

Office Copay $_____________________

Lawyer’s Name ______________________________________

Phone _______________________________________

The reason for my visit today is: (circle one)

Medical Auto accident Worker’s Comp Other

Have you had the following: NO WANT IT Flu shot _____ ________

Pneumonia shot _____ ________

Hepatitis B Vaccine _____ ________

Shingles vaccine _____ ________

Other _____________ _____ ________

List the medications you are taking:

Prescription:

____________________________ Dose ____________

Over the Counter:

____________________________ Dose ____________

Vitamins/Herbs/Minerals/Other:

____________________________ Dose ____________

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Current Problems:

(Please list all current problems you are experiencing. List the

most severe first, the second most severe next, etc.)

Problem Date of Onset

1. ______________________________

______________

2. ______________________________

______________

3. ______________________________

______________

4. ______________________________

______________

5. ______________________________

______________

6. ______________________________

______________

Do you have, or have you ever had, any of the following?

(check all that apply) _____

head trauma

_____ blindness, cataract, glaucoma

_____ trouble hearing, hearing aids

_____ allergic rhinitis, sinus infections

_____ dentures

_____ heart problems, angina, murmur

_____ high blood pressure, low blood pressure

_____ aneurysm

_____ asthma

_____ bronchitis, pneumonia, COPD, emphysema

_____ cirrhosis, gallbladder disease

_____ GERD, Heartburn, hiatal hernia, ulcer

_____ hepatitis, jaundice

_____ hemorrhoids

_____ hernia

_____ incontinence

_____ kidney disease, UTI

_____ STDs

_____ arthritis, gout, muscular injury, skeletal injury

_____ dermatitis, moles, psoriases

_____ epilepsy, seizures

_____ stroke, TIA

_____ severe headaches, migraines

_____ bipolar disorder

_____ depression

_____ hallucinations, delusions

_____ thoughts of suicide, suicide attempts

_____ goiter

_____ cholesterol problems, thyroid problems

_____ high blood sugar, diabetes, low blood sugar

_____ anemia

_____ cancer

_____ HIV

_____ TB

_____ Other _________________________________________

Surgeries: Type

Year _____________________________

__________

_____________________________ __________

Hospitalization History:

Year Length of Stay

Reason

_____

___________

_______________________

_____

___________

_______________________

Do you use tobacco?

YES NO

Do you drink alcohol?

YES NO

Do you use illicit drugs?

YES NO

Do you eat healthy meals?

YES NO

Do you regularly exercise?

YES NO

Do you take daily aspirin?

YES NO

Does your home have Smoke detectors?

YES NO

Do you keep firearms in your home?

YES NO

Do you wear seatbelts?

YES NO

Have you had exposure to STDs?

YES NO

So you practice safe sex?

YES NO

If female:

Date of onset of last mensus __________________

Have you ever been pregnant? _________________

Have you given birth? _______________________

Have any of your family had any of the following?

_____

arthritis

_____

asthma

_____

bleeding disorder

_____

heart disease

_____

diabetes

_____

high cholesterol

_____

hypertension

_____

lung disease

_____

mental illness

_____

osteoporosis

_____

stroke

_____

Cancer if yes, what type?

_________________________________________

_____

other ____________________________________

List all allergies (if none, check the blank below):

____ No known allergies Medications _______________________________

Foods ____________________________________

Other ____________________________________

I acknowledge that I have been

provided KPMC’s Notice of Privacy Practices ________________________________

____

Signature of Patient or Personal Representative

Date

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Name ___________________________________________________________ Date _____________________________________

No Show and Cancellation Policy

I understand that if I fail to show up for my appointment without 24 hours notice I may be subject to a “No Show” fee that is not billable to insurance. I also understand that if I fail to show up for my appointment without notice of cancellation 3 times, any future appointments will be made when the appointment is pre-paid. This is non-refundable and will NOT be credited to future appointments.

Financial Policy

I understand that charges incurred for services rendered by Kiest Park Medical Clinic or Smart Living Medical Center are my responsibility, regardless of insurance coverage. I understand and agree that insurance policies are an agreement between the insurance carrier and me; and not between my insurance carrier and Kiest Park Medical Clinic or Smart Living Medical Center. Furthermore, I understand KPMC/SLMC will prepare any necessary reports and forms to assist in making collections from my insurance company and that any amount authorized to be paid directly to KPMC/SMLC will be credited to my account upon receipt.

Assignment will be accepted for all insurance with which KPMC/SMLC participates. It is my responsibility to provide this office with accurate insurance information and to notify KPMC/SLMC of any changes in health insurance coverage. If I have any questions on net- work status/participation with my insurance , it is my responsibility to contact the customer service number on my insurance card.

I understand if any insurance company sends a check or reimbursement to me; THE CHECK DOES NOT BELONG TO ME. I am to bring the check and Explanation of Benefits to KPMC/SMLC.

Patient Responsibility:

If my insurance has an office co-payment, co-insurance, or deductible that has not been satisfied, I must pay this at the time of my appointment. I understand that charges for professional services rendered are due and payable immediately. Any amount unpaid by my insurance company is my responsibility and is due immediately upon notification of the denial by my insurance company. I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. All cost for my care is my responsibility. I agree that I will be responsible for all attorney and legal fees if legal action becomes necessary to collect.

Billing: Know your insurance policy

I understand that I am responsible for any rejected claims, non-covered expenses, deductibles, co-insurance/copayments. Cash, money order, Visa and Master Card are acceptable means in which to pay the balance.

I understand that at times, no matter how diligent KPMC/SLMC’s billing might be, my insurance company might decline a claim for services. In that event, it is most effective for me to contact the insurance company since I am their paying customer. KPMC/SLMC’s billing department will be glad to assist me, but I may be asked to intervene as that is the most effective means of settling disputes with my insurance company.

If there remains an unpaid balance and I make no payment or make no contact as the responsible party despite all KPMC/SLMC’s ef- forts to contact me, then my account could be turned over to a collection agency or pursued legally.

Informing our patients about our financial policy assists us in providing the best service to our patients.

Thank you for taking the time to read this policy statement.

Should you have further questions or comments, please kindly contact our Business Office Supervisor.

I hereby understand the financial policy of this practice. I guarantee payment of all charges incurred for the account of the patient named below. I further agree to pay any attorney’s fees, court costs, and related collection fees incurred. I also agree that my employer may be contacted to verify employment status.

Patient name/Signature ____________________________________________________________ Date _________________________

Guarantor/Responsible Party Signature _______________________________________________ Date _________________________

Dr. Louis Zegarelli

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Dr. Louis Zegarelli

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Dr. Louis Zegarelli

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Dr. Louis Zegarelli

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Patient Release of Medical Records Form (Please Print or Type)

To:

Name of Clinic/Physician _________________________________________________

Address _________________________________________________

Phone# _________________________________________________

Fax # _________________________________________________

Patient's Name:__________________ request and give my permission to release my Medical Records for the time period dating from_ to _________

The Medical Records as listed above are to be released to:

Dr. Louis Zegarelli 4230 W Green Oaks Blvd

Arlington, TX 76016 817-200-7533 Fax: 817-476-6051

Printed Patient Name _________________________________________________

Date of Birth _________________________________________________

Social Security # _________________________________________________

Patient’s Signature _________________________________________________

Today's Date _________________________________________________

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MVA Accident Questionnaire

Dr. Louis Zegarelli

Name __________________________________________ Date _______________________

Date of Accident _____________________________ Time of Accident ___________________

Road conditions at time of accident ________________________________________________

Were you the driver? YES NO Were you the passenger? YES NO

Where were you seated in the vehicle? FRONT BACK LEFT RIGHT Were you transported by Ambulance? YES NO

Were you seen in the Emergency Room? YES NO Were you admitted to the Hospital? YES NO Were X-rays or an MRI done? YES NO

Patient Car Year ____________ Make ____________ Model __________ Speed __________

Other Car Year _____________ Make ____________ Model___________ Speed __________

Please draw your accident

Please describe your accident

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Describe your injury (injuries)

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

MVA Accident Questionnaire

PLEASE PRINT CLEARLY

Dr. Louis Zegarelli

I acknowledge that I have been

provided KPMC’s Notice of Privacy Practices ________________________________

____

No Show and Cancellation Policy

Financial Policy

Patient Responsibility:

Billing: Know your insurance policy

Dr. Louis Zegarelli

Dr. Louis Zegarelli

Dr. Louis Zegarelli

Dr. Louis Zegarelli

Patient Release of Medical Records Form (Please Print or Type)

To:

Name of Clinic/Physician _________________________________________________

Address _________________________________________________

Phone# _________________________________________________

Fax # _________________________________________________

Patient's Name:__________________________ request and give my permission to release my Medical Records for the time period dating from_________________ to _________________

The Medical Records as listed above are to be released to:

Dr. Louis Zegarelli 4230 W Green Oaks Blvd

Arlington, TX 76016 817-200-7533 Fax: 817-476-6051

Printed Patient Name _________________________________________________

Date of Birth _________________________________________________

Social Security # _________________________________________________

Patient’s Signature _________________________________________________

Today's Date _________________________________________________

Dr. Louis Zegarelli

Have you contacted a lawyer? YES NO If yes, lawyer’s name ___________________________

Lawyer phone number _________________________________________

Lawyer Address ______________________________________________

Do you have a Letter of Protection? YES NO

If yes, you must present a Letter of Protection during your first office visit.

Will your auto insurance be billed for this accident? YES NO Have you filed a claim? YES NO

Name of Insurance Company _________________________________________________________

Claim # __________________________________

Adjustor's Name ___________________________ Adjustor's Phone Number _________________

Is anyone else responsible for your charges? YES NO If yes, whom? _________________

Address ___________________________________________ Phone # ____________________

Have you seen any other doctor, hospital, Emergency Room, Clinic, or other medical professional or facility in relation to this accident? YES NO

If YES, whom/where? ________________________________________________________________

Date(s) you were seen _______________________________________________________________

Motor Vehicle Accident Financial Information Form

Name ____________________ Date _

Date of Accident ___________ Time of Accident _

Patient Car Year Make Model Speed

Other Car Year _______ Make Model_ Speed ______

Patient's Name:__________________ request and give my permission to release my Medical Records for the time period dating from_ to _________

Adjustor's Name ___________ Adjustor's Phone Number _

Address _______________________ Phone #