Automobile Accident Questionnaire
Devine Chiropractic & Rehab Center
Reason for VisitIs your condition a result of: Work Auto Accident Trauma Chronic Other
Briefly describe what happened When did this condition begin? Is it getting better or worse?
Have you had a similar condition in the past? Yes No
Have you seen any other doctors for this condition? Yes No
If Yes, whom?
Have you ever had chiropractic care before? Yes No
If Yes, whom?
Health HistoryPlease list any surgeries/hospitalizations that you have had and the dates:
Please list serious past injuries and the dates:
Please list all serious medical condition/allergies that you have or ever had:
Please list all family members with major medical conditions:
Are you taking any of the following medications? Nerve Pills Pain Killers Muscle Relaxers Insulin Blood Thinners Tranquilizers Others
Do you take: Vitamins Supplements Do you exercise? Yes No. If yes, how much?
Are you wearing: Heel Lifts Sole Lifts Orthotics Arch Support
Do you smoke? Yes No. If yes, how much? How long?
For women: Are you pregnant? Yes No. Do you take birth control? Yes No.
When was your last cycle?
Do you currently have or ever had any of the follow diseases or conditions?
Please diagram your problem areas above using the symbols below and rate the intensity of the pain on a scale of 1-10. A 10 represents the worst pain imaginable. Circle all areas of pain that do not fit the descriptions below.
New Patient Promise
Our promise is based on the simple truth that if we satisfy and care for our patients, they will get well faster and be more likely to share their chiropractic experience with others.
Since chiropractic results vary, we can?t guarantee results, but we can promise your satisfaction. So, within seven days of beginning care, if you are not completely satisfied with your decision to begin chiropractic care, we will gladly refund the money you have paid us. Since most spinal problems involve muscles and soft tissue that are slow to heal, continued chiropractic care is often required for maximum improvement.
A clear definition of our policy allows us to concentrate on restoring and maintaining your health. We are always happy to answer any questions that you may have regarding our policy, your account, or your insurance coverage. Insurance Information
Health and accident insurance policies are an agreement between the insurance carrier and you. We will gladly prepare any necessary reports and forms to assist you in filing claims with your insurance company. Any amount authorized to be paid directly to Devine Chiropractic & Rehab Center, P.S. will be credited to your account upon receipt.
All services rendered to you are charged directly to you and you are personally responsible for payment. In order to facilitate the correct and rapid processing of your insurance claim, you can do the following: Call your insurance agent to determine exactly what coverage you have. Ask what deductible, if any, applies to your policy, and how much of your claim your insurance company will pay. If you have any questions, feel free to ask. Our staff is experienced in insurance claim handling and will be glad to assist in any way they can.
1. If you have been in an auto accident or have been hurt on the job, we suggest that you discuss your coverage with our insurance office. We may have suggestions that will help you in this regard.
2. You will be asked to authorize Devine Chiropractic & Rehab Center, P.S. to furnish information regarding your case directly to your insurance company and to assign all benefits as a result of the claim. This will expedite its handling.
Patient Payment Schedule
Our patients? health needs are paramount. Patients are allowed to receive the care they need and reduce the balance on a monthly schedule rather than paying for visits as they are received. Monthly payments are required on all unpaid balances.
Please notify our office if you are unable to keep your schedule appointment. You will not be charged for missed chiropractic appointments. Should you need to cancel or reschedule a massage appointment, we require at least 24 hours? notice. Missed massage appointments without 24 hours? notice will be charged unless that time can be filled by another patient.
If you move from our area, we will be glad to refer you to another chiropractor. We will forward your x-rays and records after you sign a release transfer.
If you terminate your care at Devine Chiropractic & Rehab Center before your doctor feels your condition has stabilized, any fees for professional services will be immediately due and payable, unless prior arrangements have been made.
Other uses of medical information: We will ask for your written authorization before using or disclosing medical information about you in any other situation not covered by this notice. If you choose to authorize use or disclosure you can later revoke that authorization by notifying us in writing.
Your rights regarding personal medical information: In most cases you have the right to look at or get a copy of medical information that we use to make decisions about your care after submitting a written request. We may charge a fee for the cost of copying, mailing, or related supplies. If we deny your request to review or obtain a copy of your medical record, you may then submit a written request for a review of that decision.
You have the right to request that medical information about you be communicated to you in a confidential manner, such as sending mail to an address other than your home, by notifying us in writing.
We are not legally required to accept you request, but will consider it and inform you of our decision. All written requests or appeals should be submitted to Dr. James A. Devine.
If you are concerned that your privacy rights may have been violated, or you disagree with a decision we made about access to your records, you may contact Dr. James A. Devine at 104 pike St Suite 210, Seattle, WA 98101.
I hereby authorize the Doctor to treat my conditions as he or she deems appropriate. It is understood and agreed that the amount paid the Doctor, for x-rays, is for the examination only and the x-ray negatives will remain the property of this office, being on file where they may be seen at any time while a patient of this office. The patient also agrees that he/she is responsible for all bills incurred at this office.
By signing my name below, I acknowledge receipt of a copy of this notice, and my understanding and agreement to its terms.Printed Name
Consent to Treat Minor Date
Guardian Signature Authorizing Care Date
Notice of Privacy Practice
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
The information privacy practices in this notice will be followed by:
Our pledge to you: We value you as a patient and appreciate the opportunity to serve you. We are committed to protecting medical information about you. We create a record of the care and services you receive to provide quality care and to comply with legal requirements. By law, we are required to:
Changes to this notice: We may change our policies at any time. Changes will apply to medical information we already hold and to the future information after the change occurs. Before we make significant change to our policies, we will alter our notice and post the new notice for public view in our office. You can receive a copy of the notice at any time. You will also be asked to acknowledge in writing your receipt of this notice.
How we may use and disclose your personal medical information: We may use and disclose medical information about you for any purpose regarding your treatment, to obtain payment for treatment (such as sending billing information to your insurance company or Medicare), and for health care operations (such as comparing practice patterns to improve treatment methods).
I understand that my doctor?s recommendations are paramount for my optimum health and the improvement of my condition. Failure to follow my doctor?s recommendations may hinder or prolong my recovery and increase the number of visits required to correct my problem.
I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures including, but not limited to, diagnostic x-rays on me (or the patient named below, for whom I am legally responsible) by any licensed doctor of chiropractic who treats me at Devine Chiropractic & Rehab, P.S.
I have had the opportunity to discuss with my doctor at Devine Chiropractic & Rehab Center, P.S. and/or other office personnel the nature and purpose of chiropractic adjustments and other procedures.
I understand an am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment, including, but not limited to fractures, disc injuries, strokes, dislocations, and sprains. I do not expect the doctor to be able to anticipate and explain all of the risks and complications of the procedure which the doctor feels at the time, based upon the facts then known, is in my best interest.
To Be Completed by PatientPatient Name:
Witness to Patient?s Signature:
If Patient is a Minor, Physically, or Legally Incapacitated to be completed by Patient?s RepresentativePatient?s Name:
Name of Representative:
Signature of Representative:
Relationship of Authority of Patient?s Representative:
PERSONAL INJURY BILLING INFORMATION
Date of Injury
Do you have Personal Injury Protection? Yes No I DON?T KNOW
Have you opened a claim with your insurance company? Yes No
Auto Ins. Comp.
Policy #: Insurance Co. Phone #
Claims Ins. Co. Address
Claims Adjuster Claim #
Do you have an attorney? Yes No
Please fill in information below if your answer is yes
Attorney?s Name Phone
Other Driver?s Name
Ins. Comp. Phone
Policy # Claim #
All of the above information is correct to the best of my knowledge. I agree that Devine Chiropractic will bill my insurance company, however, I also agree that any balance owing is ultimately my responsibility.Signature Date
Payment Plans for Chiropractic and Massage
To All New Patients: Please initial next to your method of payment
Insurance Patient: Our office provides a courtesy verification of your benefits with your insurance information. This is through our third party medical billers which will give us benefit information within 24 hours. We recommend that you call your insurance company to verify that they will cover our in-network doctor, Dr. James Devine, along with x-rays. We recommend that you should know the details of your insurance (and if a deductible or co-pay applies). We will bill your insurance as a courtesy to you, with the understanding that you are ultimately responsible for your account in our office. All co-pays are expected at the time of your service. If you do not know what your copay is, you will be required to pay $25 per visit until the correct amount of your co-pay has been determined.
Personal Injury Patient: It is your responsibility to provide our office with all insurance information; including PIP, third party, health insurance, etc. We need all claim numbers, adjuster/manager contact information, and insured person?s name, address, and phone numbers. You are responsible for payment to our office for any services rendered.
Labor & Industries Patient: You are responsible for filling out Labor & Industries long form or the form for self-insured L&I. You are also to have an accident report filed with your employer. If your claim is not accepted, you will be responsible for your account balance.
Cash / Private Pay Patient: To receive our discounted rate, payment is required at the time services are rendered. We accept all forms of payment (Cash, Personal Checks, Visa, MasterCard, American Express).
**I understand that any missed massage appointments without 24 hour notice will incur a $40 fee.
** understand that future appointments will not be scheduled until the missed appointment fee has been paid.Date:
Dr. James Devine, DC
Dr. Sarah Flood, DC
Dr. Ben Greenwade, DC
Dr. James Barthelme, DC