New PI Form
New Personal Injury/Auto Accident Forms
CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION
I understand that this organization originates and maintains health records which describe my health history, symptoms, examination, test results, diagnoses, treatment, and any plans for future care or treatment.I understand that this information is used to:
▪ Plan my care and treatment▪ Communicate among health professionals who contribute to my care▪ Apply my diagnosis and services, procedures, and surgical information to my bill▪ Verify services billed by third-party payers▪ Assess quality of care and review the competence of healthcare professionals In routine healthcare operations
I further understand that:
▪ A complete description of information uses and disclosures is included in A Notice of Information Practiceswhich can be provided to me at my request
▪ I have a right to review the notice prior to signing this consent▪ The organization reserves the right to change their notice and practices▪ Any revised notice will be mailed to the address I have provided prior to implementation▪ I have the right to object to the use of my health information for directory purposes▪ I have the right to request restrictions as to how my health information may be used Or disclosed to carryout treatment, payment, or health care operations▪ The organization is not required to agree to the restrictions requested▪ I may revoke this consent in writing, except to the extent that the organization has already taken action inreliance thereon
I request the following restrictions to the use or disclosure of my health information:
HEALTH CARE AUTHORIZATIONThe above named patient authorizes the staff of Pain 2 Wellness Center, LLC to use and/or disclose protectedhealth information in accordance with the following specific authorizations:1. Contact Authorization. I give permission to Pain 2 Wellness Center to use the following information, but notlimited to my: address, phone number, and clinical records to contact me with appointment reminders, missedappointment notification, birthday and any other holiday related cards, and to display a picture of my automobileaccident on a bulletin board. If Health Authority contacts me by phone, I give them permission to leave a phonemessage on my answering machine or voice mail.2. Open Room Authorization. I give Pain 2 Wellness Center permission to treat me in an open room where otherpatients are also being treated. I am aware that other persons in the office may overhear some of my protected health information during the course of care. Should I need to speak with the doctor or staff at any time inprivate, they will provide a room for these conversations.3. Right to Establish Payment. I authorize and grant power of attorney to any approved agents of Pain 2 WellnessCenter to act with any insurance company regarding claims, payment of my treatment, and collection for bills.This includes full permission to establish a medical or accident claim, on my behalf, and create paymentprotection that would relate to the payment of any healthcare services. Any statements or documents, related oraffecting treatment services that would prevent or deny insurance payments to this office are to be made nulland void by the receipt of this form. I intently grant an assignment of benefits as letter of credit against myinsurance claim(s) for direct payment to this office. I further authorize the release of any information regardingmy coverage on my insurance policy, or any future claim settlement status from the associated insurancecompany(s) their attorney(s) and/or my personal attorney(s).This authorization is requested by Pain 2 Wellness Center for its own use/disclosure of PHI. (Minimum necessaryHIPPA standards apply.) You have the right to refuse to sign this authorization. If you refuse to sign thisauthorization, Pain 2 Wellness Center LLC, retains the right to refuse treatment or may offer to providetreatment on a pre-paid basis.
Relationship to Patient:
In an effort to maintain compliance with various state and federal regulations, managed care and preferredprovider agreements, as well as billing and coding guidelines, we have adopted the following financial policies:Our clinic has established a single fee schedule that applies to all patients for each service provided. You may be entitled to a network or contractual discount under the following circumstances:
▪ If we are a participating provider in your health plan.▪ If you are covered by a State or Federal program with a mandated fee schedule.▪ We are a network provider in a Discount Medical Plan Organization (DMPO) that you may join. Patients who are uninsured, or underinsured (limited benefits for chiropractic care). Ask our team for more information. DMPOs CANNOT BE USED FOR INJURY CLAIMS▪ If you are eligible & choose a pre-payment plan, auto-debit plan or “prompt payment” option. We offer weekly, monthly, or yearly payment
As part of plans. our compliance plan, our office will be unable to extend any type of discounts other than thoselisted above. We are committed to providing you with the best chiropractic care possible in a caring environmentand have established our financial policies to achieve that goal. Details of your care plan will be discussed withyou during your Chiropractic Report. To assist you with your healthcare investment, we provide the followingpayment options:
• Cash - includes money orders and personal checks• Credit Cards – MasterCard, Visa, and American Express• Auto-Pay – an auto debit payment program that uses debit cards or credit cards
Health Insurance: If you have insurance that covers chiropractic, we will file all of the information for you. Thisincludes your diagnosis, prognosis, and copies of your records or reports. Remember, you agreement with yourinsurance company is between you and them. If for some reason your insurance does not pay what we expect,you will be responsible for the balance. We file your insurance only as a courtesy for you. We will discuss thisoption with you during your Chiropractic Report. ALL DEDUCTIBLES AND CO-PAYMENTS must be paid prior toservice. Special Situations: i.e. AUTO INJURY OR WORKERS COMP
If you choose to use insurance for a special injury claim, such as an auto accident or a workers compensationinjury, your “normal insurance” or DMPO will be “frozen” until such claim is closed. Your personal “HealthInsurance” is not required to pay “third party claims”. We will then continue on the corrective plan we havechosen for you at that time.
Medicare patients: Medicare offers very limited coverage for chiropractic treatment. Medicare does not coverX-ray examinations, physical examinations, extremity adjustments, hot/cold treatments, traction or othertherapies performed by a Chiropractor. Medicare will only cover chiropractic spinal adjustments.
Office Fee Schedule
SERVICE OFFICE FEE Consultation N/C-$100 99201 – 99205 Initial Exam (Brief-Comp.) N/C-100 99211 – 99215 Est. Re-Exam (Brief-Comp.) $100-$250 X-Rays (per view) $50-$20 BY REFERRAL
98940 Adjustment (1-2 regions) $61 98941 Adjustment (3-4 regions) $73 98942 Adjustment (5 plus regions) $85 98943 Adjustment (extremities) $40 97035 Ultrasound 15 min or less $45 97014 Electric Stimulation 15 min or less $40 97012 Mechanical Traction 15 min or less $50 97110 Therapeutic exercises 15 min or less $65 97530 Therapeutic procedures 15 min or less $60 97535 Self Care Home Therapies 15 min or less $77 Wellness & Corrective Adjustment Plans Patient Based on individual needs
Statement of Understanding:I have read the codes and fees and understand the cost of my care with my treating doctor. I understand that Iam responsible for payment of all deductibles and co-payments related to my care. I understand that if I have abalance for medical services not paid, I will make a minimum of $50.00 each month or 20% (auto-debit) of theoutstanding balance whichever is greater. If my balance is not paid in a timely and monthly fashion, I promise topay any and all service, collection, court, and attorney fees in the collection of my account. I further understandthat if my treatment is associated with a personal injury or accident claim, all medical bills will be paid at 100%of the above fee schedule regardless of the outcome of my case. I also agree to Pain 2 Wellness Center filing alien against the settlement of aforementioned case. I am aware that if my case is not settled 90 days after theend of treatment my account will be placed in collections. I understand that if a check or debit is returned forinsufficient funds, I will be charged a $25.00 service charge. I further understand that if my insurance companydeclines payment, I authorize Pain 2 Wellness Center to file small claims on my behalf against my insurancecompany as a method of collection. I further understand that I will be present at the court date if needed.
I have read and fully understand the above financial terms, policies, and prices.
Office Policies and ProceduresIn order to provide the best care for our patients, all patients are accepted for care based in the followingpolicies: Please read and Initial each of the following policies:
Office Hours: Monday, Wednesday, Thursday, and Friday, our office will openpromptly at 9:00 am. We close daily 1:00-3:30 to allow time for staff meetings, trainings, and lunches. We closefor the day 7:00 pm, with the exception of Thursday, where we will close at 1:00 pm Our last appointment isaccepted 30 minutes before each closing time. We are closed on Tuesdays.
Treatment Plans: Care plans are individualized for each patient based on their individual needs, goals, and condition of their spine. It is the responsibility of the patient to follow their treatment plan to receive the full benefits of their program. Changes to treatment plans or visit frequency will be made at specific re-evaluations based on progress. Please understand that we do not base your care plan on your extended insurance coverage, and neither should you. There are limits to what they will pay. Our goal is tocorrect your problem in the shortest amount of time possible and in the most cost-effective manner. You willachieve the best results when you follow the practitioner’s recommended appointment schedule and home careadvice. Remember: healing takes time. If you do not feel satisfied with your body’s responses, please requestextra time for your next appointment to discuss this with your practitioner. We want you to get the most fromyour care.
Back Office: Our patient’s treatment and privacy are of upmost importance to our office. To stay in compliance with our privacy policies, we ask all patients to please refrain from entering the treatment area without assistance from the staff
Reading of Reports: If you have completed the recommended MRI or otherimaging, please inform the front desk so that they may schedule a time for you to go over those results with thedoctor. Remember to bring in your MRI disc provided to you at the time of your appointment
Medical Record and Forms: Copying and transfer of medical records requires a signed release by the patient. There is a pre-payment required before records can be copied. The fee to pick up your medical records is $25. If you want your medical records mailed, the fee is $28. Once payment is received, please allow up to 7 business days to prepare and mail records. If you would like to pick them up, we will contact you once they are ready. If you require services, documents or documentation that fall outside of our normal office visit procedures, such as: letters of medical necessity, or work equipment requests, please allow aminimum of five business days for response and/or receipt of the requested. Due to the requiredtime, the doctor may charge a fee of up to $200 per set of forms
New Patient Orientation: It is required that all patients watch “New PatientOrientation” health workshop. This workshop will be sent to you via email. We have found that the patients whofollow this recommendation GET BETTER FASTER AND SPEND LESS MONEY.
Personal Injury Patients: Personal injury patients must stay consistent withadjustments and notify the office of any changes with adjusters or attorneys. Personal injury patients will be billed in the following order:
1. 1st Party-Med pay – Patient auto insurance2. 3rd Party Liability – At fault party (must have Attorney representing)3. Under or Uninsured Motorist – Patient’s auto insurance4. Personal Health Insurance – Must have proof that all other venues have been exhausted
X Ray Consent: During your examination, the doctor may feel that x-rays will be needed in order to diagnosisyour condition. We would like to make you aware that x-rays may be required in order to administer treatment.Before we perform x-rays on any patient our office requires the patients consent for such tests to be performed.
Please read the statements below and select ONE choice Do not initial both.
I understand that my doctor may need x-rays in order to diagnosis my condition and I give permission of all needed diagnostic tests.
I understand that my condition may require my doctor to take x-rays to further diagnosis my symptoms. I choose NOT to have any x-ray at this time and release my doctor of all liabilities.
FEMALES ONLY: I understand that if I am pregnant and have x-rays taken which expose my lower torso toradiation, it is possible to injure the fetus. I have been advised that the ten (10) days following onset of amenstrual period are generally considered to be safe for x-ray exam. With those factors in mind, I am advisingmy doctor that I am not pregnant.
Our clinic reserves the right to deny services to anyone for any reason, or if the doctor feels that the patient’shealth is not being best served. Statement of Understanding: I have read and fully understand the above terms and office policies listed above.
NO SHOW/MISSED/LATE APPOINTMENT POLICY
We, at Pain 2 Wellness Center understand that sometimes you need to cancel or reschedule your appointmentand that there are emergencies. If you are unable to keep your appointment, please call us as soon as possible (with at least a 24- hour notice). You can cancel appointments by calling the following number: 404-699-0966 or via email at firstname.lastname@example.org
To ensure that each patient is given the proper amount of time allotted for their visit, short wait times, and toprovide the highest quality care, it is very important for each scheduled patient to attend their visit on time. As a courtesy, an appointment reminder text to you is made/attempted one (1) business day prior to your scheduled appointment. However, it is the responsibility of the patient to arrive for their appointment on time.
1. If less than a 24-hour cancellation is given this will be documented as a “No-Show” appointment.2. Any “No-Show/Missed” appointments will be assessed a $25.00 no show fee. This fee is not covered by insurance or any personal injury case and must be paid prior to your next appointment.3. If you arrive more than 15 minutes past your scheduled appointment time you may still be seen if ourschedule permits. You will be moved to a walk in. This could result in longer wait times as patients with scheduled appointments will be seen first.4. Multiple “no shows” in any 6 month period may result in termination from our practice.
Cell Phone Usage Policy
Pain 2 Wellness Center is a place of healing. In order to allow all patients proper relaxation, we require all phones be placed on silent upon entering the office. This includes all notification and any videos. If you receive an emergent call, we ask you take our call outside. Once you have completed your call, please inform the front desk staff so that the staff will know you are ready to begin treatment. If you are unavailable, staff will move on to the next patient.I have read and understand Pain 2 Wellness Center’s No Show/Missed/Late Appointment Policy and “Cell Phone Usage Policy” and understand my responsibility to plan appointments accordingly and notify Pain 2 Wellness Center appropriately if I have difficulty keeping my scheduled appointments.
Motor Vehicle Accident Questionnaire
INFORMATION ABOUT YOUR ATTORNEY
Office Phone Number: Office Fax Number:
INFORMATION ABOUT YOUR ACCIDENT
Date of Accident:
Date of Accident: Date of Accident:DriverFront Seat PassengerRear Right Seat PassengerRear Left Seat Passenger3rd Row Right Seat Passenger3rd Row Left Seat Passenger
What position was your headrest? What position was your headrest?Low Mid PositionHigh
Did you head hit the headrest? Did you head hit the headrest?YesNo
Did any part of your body strike any part of the vehicle? Did any part of your body strike any part of the vehicle?YesNo
If yes, what body part hit what part of the car?
Were you knocked unconscious? YesNo
If yes, for how long?
Type of vehicle you were in: was it a CarSUVTruckVan Size of your vehicle SmallMid Size Large
Type of Vehicle that hit you: Type of vehicle you were in: was it a CarSUVTruckVan Size of the vehicle that hit you. SmallMid Size Large
Was your vehicle equipped with airbags? YesNo
If Yes, Did they inflate? YesNo
At the time of impact where were you looking? LeftRightStraight AheadDownNot Sure
Were you struck from: FrontRearLeftRight
Were the police notified? YesNo If yes, was a report taken? YesNo
Did EMS arrive on scene? YesNo If yes, were you transported to the hospital? YesNo
Approximate Speed of your vehicle. MPH
Approximate Speed of other vehicle. MPH
In your own words, please describe the accident:
Estimated Damage to your Vehicle: NoneSlightModerateHeavy
Was your vehicle towed from scene? YesNo
Estimated Damage to the other Vehicle: NoneSlightModerateHeavy
Please describe how you felt: (e.g. “I had a dull ache at the back of my neck”)
a. DURING the accident:
b. IMMEDIATELY AFTER the accident:
c. LATER THAT DAY:
d. THE NEXT DAY:
CHECK SYMPTOMS YOU HAVE NOTICED SINCE THE ACCIDENT:
Have you lost time from work as a result of this accident? YesNo
Last day worked: Type of Employment
How many hours per night of sleep before the accident? Since the Accident?
Have you been treated by another doctor since the accident? YesNo
If yes, by whom and when:
Have you attempted to self treat at home? YesNo
Since the injury occurred, are your symptoms: ImprovingGetting WorseSame
Extension of Credit, Lien and Assignment of Benefits*In consideration for this office providing services to me, and because I do not have sufficient fundsavailable to pay in advance for care; I hereby seek credit and grant a lien to this office against any and allproceeds resulting from and arising out of the negligence of a third party, causing injuries and the needfor reasonable and necessary health care, which this office, shall provide. Because services are to berendered in reliance upon this agreement, I agree this agreement shall be irrevocable after being signed.In the event I change or substitute my attorney, this lien shall be binding upon any subsequent attorneyupon being furnished a copy of this agreement. This shall not imply that the services are being providedon a contingency basis. I direct any insurance company, attorney or other person who holds or later holdsproceeds from my claim to apply it directly to my account at this clinic.*If using an attorney, now or in the future, I irrevocably direct them to follow State Bar of Georgia - RULE1.15(I) SAFEKEEPING PROPERTY – GENERAL, and direct them to honor all debts to this clinic. Theycan negotiate for me but my attorney is not to release funds directly to me without honoring this debt. Mylawyer has a duty under applicable law to protect such third-party claims against wrongful interference bytheir client (me), and accordingly may refuse to surrender the property to me until an agreement is madeconcerning my debt to this clinic. If my attorney does not honor this agreement they will be in violation ofGeorgia Bar Rule 1.15(I).*I also authorize and direct my attorney to sign any liens or letters of protection from this office.
Assignment of Benefits and Direct Payment:*I direct my attorney, insurance company or claims adjuster, to pay any outstanding bills out of mysettlement or med pay benefits, in effect; protecting any such balance and pay this money DIRECTLY tothis office. I assign proceeds from my claim to PAIN 2 WELLNESS CENTER, LLC (Tax 02-0721783) topay for treatment and services rendered by this Clinic. I irrevocability request and direct that payment besent directly to this clinic.
*I further personally guarantee payment to this office against the proceeds of any settlement, judgment orverdict. If the case does not settle the debt is still due. I also understand that I am responsible for allcollection and court cost associated with collecting this debt. Payment is not contingent on receipt of asettlement. I realize that I am responsible to make sure payment is made to your office and I will updateyour office once a month concerning the status of my case.
I hereby authorize and direct my insurance company, insurance administrator or attorney to pay by check,and for it to be mailed directly to our office the expense benefits allowable, as payment toward the totalcharges for professional services rendered. I agree to pay, in a current manner, any balances of saidapplicable charges. I agree that this office be given power of attorney to endorse any and all drafts forpayment of my bill. I understand and agree that health and accident insurance policies are anarrangement between an insurance carries and myself. I permit this office to endorse remittances for theconveyance of credit to my account. All co pays and deductibles are due at the time of service. Iunderstand that I will be responsible for all collection or court fees involved if the account has to be sentto collections.
I have read this entire document and fully understand & irrevocably agree to it.
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: New Personal Injury/Auto Accident Forms
Agree & Sign