Olivieri Chiropractic Inc. AUTO ACCIDENT INFORMATION FORM IF YOU NEED MORE SPACE, WRITE ON THE BACK OF THIS PAGE

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1 Olivieri Chiropractic Inc. AUTO ACCIDENT INFORMATION FORM IF YOU NEED MORE SPACE, WRITE ON THE BACK OF THIS PAGE NAME: AGE: DATE OF BIRTH: SEX: M F MARITAL STATUS HOME PHONE WORK PHONE ADDRESS ADDRESS ACCIDENT DATE TIME WHERE DID IT HAPPEN? GIVE A DETAILED DESCRIPTION OF HOW THIS ACCIDENT/INJURY HAPPENED. WHAT PARTS OF YOUR BODY WERE HURT? HAVE YOU EVER HURT THESE PARTS OF YOUR BODY BEFORE? IF YES, HOW AND WHEN WHERE DO YOU NOW FEEL PAIN? WHAT SYMPTOMS/PROBLEMS BEGAN FROM THE ACCIDENT? WHAT SYMPTOMS/PROBLEMS DO YOU FEEL RIGHT NOW? HAVE YOU EVER HAD THESE SYMPTOMS/PROBLEMS BEFORE THE ACCIDENT? IF YES, WHEN AND FROM WHAT? WHERE WERE YOU IN THE VEHICLE? WHAT TYPE OF VEHICLE? WHAT WAS THE SPEED OF YOUR CAR AT IMPACT? WERE YOU ACCELERATING AT IMPACT? WHAT WAS YOUR VEHICLE DOING JUST BEFORE IMPACT? WHAT WAS THE POINT OF IMPACT ON YOUR CAR? HOW MUCH DAMAGE WAS DONE TO YOUR CAR? [ ] UNKNOWN [ ] APPROXIMATELY $ DESCRIBE THE ROAD CONDITIONS AND VISIBILITY WERE OTHER VEHICLES INVOLVED? HOW MANY? WAS POLICE REPORT FILED? WHICH VEHICLE HIT THE OTHER? AIRBAGS DEPLOY? LOSE CONSCIOUSNESS? EMERGENCY CARE AT SCENE? WHAT WAS THE POSITION OF YOUR HEADREST? WERE YOU WEARING A SEAT BELT? WHAT TYPE IMMEDIATELY AFTER THE ACCIDENT WHERE DID YOU GO OR WHERE WERE YOU TAKEN? WERE YOU PREPARED FOR IMPACT? WAS YOUR FOOT ON THE BRAKE AT IMPACT? DID THE IMPACT KNOCK YOUR FOOT OFF THE BRAKE? WHAT WAS THE POSITION OF YOUR HEAD AND NECK AT IMPACT? WHAT WAS THE OTHER VEHICLE TYPE? SPEED OF OTHER VEHICLE AT IMPACT WHAT WAS THE OTHER VEHICLE'S POINT OF IMPACT? WAS THE OTHER VEHICLE ACCELERATING AT IMPACT? WHAT WAS THE OTHER VEHICLE DOING JUST BEFORE IMPACT? LIST ALL DOCTORS THAT YOU HAVE BEEN EXAMINED OR TREATED BY SINCE THIS ACCIDENT. (INCLUDE DOCTOR'S NAME, ADDRESS, TREATMENT YOU WERE GIVEN, REASON FOR TREATMENT, AND WHAT EFFECT THE TREATMENT HAD ON YOU) DID YOU MISS WORK DUE TO THIS ACCIDENT? WHAT IS THE FIRST DATE YOU MISSED HAVE YOU RETURNED TO WORK WHEN? BETWEEN THESE DATES DID YOU DO ANY WORK? IF YES, ON WHAT DATES WAS ANYONE ELSE IN THE CAR WITH YOU? WHO & WHAT RELATIONSHIP DOES THAT PERSON(S) HAVE TO YOU? HAS THAT PERSON(S) BEEN TREATED DUE TO THIS ACCIDENT? DID YOU REPORT THIS TO YOUR AUTO INSURANCE? IS THERE ANYTHING YOU CANNOT DO AS A RESULT OF THIS ACCIDENT? PLEASE BE SPECIFIC ABOUT WHAT YOU CANNOT DO:

2 AUTO INSURANCE INFORMATION: Insurance Company: Phone Number: Policy Number: Effective Date: Accident Claim Number: Adjuster s Name: Adjuster s Phone Number: To the best of my knowledge, all information above is accurate and true. I authorize my insurance carrier(s), trustees, executors, accountant, custodian & or attorney to make payment directly to Olivieri Chiropractic Inc for services rendered to me/my family. I agree to pay any balance left unpaid. I authorize Olivieri Chiropractic Inc to send bills/claims &/or reports for services rendered directly to my insurance carrier & or attorney and to release to my insurance carrier & or attorney any information needed to process my claim. I acknowledge that I am completely and fully responsible for paying all fees that I or my family incurs with Olivieri Chiropractic Inc. If I have financial difficulties/hardships, I shall pay Olivieri Chiropractic Inc according to the terms of any agreement that I make with Olivieri Chiropractic Inc. This authorization serves as a Doctor's Lien, directing my attorney to withhold from any settlement, judgment, or verdict which may be paid to my attorney or me whatever sum is needed to protect Olivieri Chiropractic Inc, and to pay Olivieri Chiropractic Inc directly from those proceeds. If Olivieri Chiropractic Inc. has to resort to collection proceedings against me, I agree to pay all collection costs including the fees of collection agents, attorneys, and court costs, in addition to paying all fees due Olivieri Chiropractic Inc for services rendered to me or my family. I authorize Olivieri Chiropractic Inc and staff to call me on the telephone to discuss appointments, treatment information, and/or any other details related to me/my family's therapy and treatment. Olivieri Chiropractic Inc. staff may leave messages about appointments on my answering machine. If I am unavailable or incapacitated, I authorize Olivieri Chiropractic Inc and/or staff to discuss my case with my spouse, parents, adult children, and/or other health care providers. Olivieri Chiropractic Inc is authorized to release any and all information requested to any other health care provider involved in my care and treatment. TODAY'S DATE YOUR SIGNATURE

3 New Patient Information 250 Newport Center Dr, Ste 102 Newport Beach, CA Ph Fx Full Legal Name Nick Name Address City St Zip Date of Birth Driver s License # SSN Sex: M F Marital Status: Married Single Divorced Address May we send you our newsletter? Yes No Home Phone Work Cell Fax How were you referred to our office? Occupation Full Time Part Time Employer Employer s Address Spouse Name Number of Children- Boys Girls Insurance Carrier Subscriber ID # Subscriber s Name (check here if same as Patient) Subscriber s Date of Birth What is the reason for your visit today? When did this condition start? Is this the first time? Yes No If no, when was the first time? Height Weight Is this a problem related to work or an auto accident? Yes No If yes, please explain: What other problems/complaints have you had in the past? (please describe in detail) Describe all past illnesses, surgeries and/or accidents and dates: Have you been treated by any other doctor? Yes No If yes, who/where/why? Have you ever been under the care of a Chiropractor before today? Yes No If yes, why? Who/Where was your previous Chiropractor? Last Adjustment Were you satisfied with him/her? Yes No If No, why? Has anyone in your family died from anything other than old age? Yes No If yes, give name, age, condition & relationship What illnesses and what physical and/or mental impairments do any of your relatives suffer from? Please give name, age, illness/impairment and relationship: Please list all activities that you can not do as a result of your condition: List the vitamins/medications you are taking: Do you smoke? Yes No If yes, how long? Describe your exercise habits Women Are you pregnant? Yes No If yes, Due Date: Water intake Typical Diet Hours of sleep per night Quality of sleep Are you interested in finding out your body fat %? Are you interested in info on our weight loss program? I agree that I am responsible for all fees charged by this office. I authorize release of this information to my insurance carrier. I authorize payment directly to this doctor s office. I authorize a copy of this authorization to be used in place of an original. Today s Date: Signature:

4 Privacy Confidentiality Statement 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. Disclosure of Information We may disclose information to other healthcare professionals and/or your insurance carrier for treatment, payment, or healthcare operations. Additional disclosures may be necessary to comply with Worker s Compensation and Public Health Laws as well as Judicial proceedings. We may contact a family member or other authorized person in the event of an emergency. Be assured that we will not disclose any information without your expressed written consent unless compelled to do so by legal authority. Further you will be contacted by phone or mail in the event a request for information is made. Appointment Reminder It is our policy to call your home on the evening prior to your scheduled appointment to remind you of your appointment time. If you are not at home we leave a message on your voice mail or with the person answering the phone. We will not leave any message that discloses confidential information. If you would like to use an alternate contact number please inform us the number you would prefer. Facility Set Up While our examination rooms are private, our office utilizes an open adjustment/therapy/exercise/rehabilitation setting. Staff and doctors will maintain policies to ensure privacy, but there may be some inadvertent disclosure to others in the facility at the same time. If there is private information that you need discussed, please request to have such discussions in a private room. Your Rights Send us a written request to see or procure a copy of the information that we have about you, or amend your personal information that you believe is incomplete or inaccurate. If we did not create the information, we will refer you to the source, such as other doctors or hospitals. Request additional restrictions on uses and disclosures of your health information. We are not required to agree to these requests and in some instances they may be prohibited by law. Request that we communicate with you about medical matters using reasonable alternative means or at an alternative address. Receive an accounting of our disclosures of your medical information, except when those disclosures are made for treatment, payment of health care operations, or the law otherwise restricts the accounting. You have the right to inspect and have a copy of your health information. There is no cost for the first copy and any copy thereafter is $25. You have the right to amend your information. Please note that we have the right to disagree with your amendments. If there is disagreement you will be provided with information about our denial of your amendment and how you may appeal the denial amendment. You have the right to a copy of the notice upon request. Complaints Complaints about your privacy rights or how your privacy is handled at this office can be directed to J.R. Privacy by calling this office or directing a letter to his attention. If you are not satisfied with how this office handles your complaint you may submit a formal complaint to: DHHS (Office of Civil Rights) 200 Independence Avenue, SW Room 509F HHH Building Washington, D.C I have read this Privacy Notice and understand my rights contained in this notice. By signing this form I provide authorization and consent to use and disclose my protected information as noted above. Patient Signature (or legal guardian) Print Patient Name Date

5 Informed Consent to Chiropractic Care Tara Olivieri D.C. 250 Newport Center Drive, Suite 102 Newport Beach, CA I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic X-rays, on me (or on the patient named below, for whom I am legally responsible) by the doctor of chiropractic named above and/or other licensed doctors of chiropractic who now or in the future treat me while employed by, working or associated with or serving as back-up for the doctor of chiropractic named above, including those working at the clinic or office listed above. I will have the opportunity to discuss with the doctor of chiropractic named above and/or with other office or clinic personnel, the nature and purpose of chiropractic adjustments and other procedures. I understand 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, sprains, and burns. I do not expect the doctor to be able to anticipate and explain all risks and complications and I wish to rely on the doctor to exercise judgment during the course of procedure which the doctor feels at the time, based on the facts then known, is in my best interest. I have read, or had it read to me the above consent. I have also had the opportunity to ask questions about its content, and by signing below, I agree to the above named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. Patient Signature (or legal guardian) Print Patient Name Date To be completed by Doctor or Staff: Witness to Patient s Signature Date

6 Patient Name: Date: Patient Guide to Scheduling Appointments We strive to provide our patients with the utmost professionalism and excellence of service. Our commitment to your health and well-being and recovery of your optimal health is something everyone in our office takes quite seriously. Because we care so much about you, we realize that it would be a disservice to you if we did not emphasize the importance of your own commitment to the care you need to receive and to the actions we ask you to do. Your adherence to the recommended number of treatments is a vital component of your healing process. Therefore, we have certain rules that need to be followed in order to ensure the most optimum results. We expect you to keep all your appointments. Please write down the dates and times of your future appointments or put them into your smart phone. We also provide a calendar with your appointment dates circled. It is vitally important that you complete all of the scheduled appointments before the date of your re-examination. Changing your re-examination date is against office policy and will delay in your healing and recovery. Listed below are the policies regarding all appointments: 1. No-Show: This occurs when a patient is scheduled for an appointment and does not call or text to cancel or reschedule and does not show up for their appointment. This will result in an out of pocket no show fee of: $45, $80 or $110 for Massage Therapy and $25 for a Chiropractic. (Initial) 2. Without 24-Hour Notice: This occurs when a patient is scheduled for an appointment and a call or text is made to cancel but does not give the office more than 24-hours notice in advance. The cancellation fee is $45, $80 or $110 for Massage Therapy. Chiropractic patients can re-schedule their appointment within one week without the assessed fee. (Initial) 3. With 24-Hour Notice: There is no fee assessed for Chiropractic and Massage Therapy appointments cancelled with more than 24-hours notice. We understand that things can happen, however, we would ask that patients do everything in their power to make up cancelled appointments in order to get the best results on their current treatment plan. All patients are encouraged to re-schedule their cancelled appointments within one week. (Initial) In instances of repeated non-compliance with scheduled visits, we also reserve the right to discontinue care. This type of behavior is disruptive, time consuming, and takes valued treatment time away from other patients, the doctors, therapists, and receptionist. A confirmation call or text is made the day before each patient s appointment. This is a courtesy service, meant to remind patients of their appointment times. However, failure to receive a call or text does not validate a missed appointment, and the appropriate fee will be assessed. By signing and initialing above, I have read and understand this guide: Signature

7 250 Newport Center Dr, Ste 102 Newport Beach, CA Ph Fx Notice of Doctor s Lien Patient s Printed Name: Claim Number: I do hereby authorize Olivieri Chiropractic Inc. to furnish you with a full report of their examination, diagnosis, treatment, prognosis, etc., of myself with regard to the accident which occurred on. (Date of accident) I hereby authorize and direct you to pay directly to said doctor such sums as may be due and owing him for medical service rendered me both by reason of this accident and by reason of any other bills that are due this office and to withhold such sums from any settlement, judgment, or verdict as may be necessary to adequately protect said doctor. And I hereby give a Lien on my case to said doctor against any and all proceeds of settlement, judgment, or verdict which may be paid to myself, as the result of the injuries for which I have been treated or injuries in connection therewith. I agree never to rescind this document and that a rescission will not be honored by the insurance carrier. I hereby instruct that in the event an attorney is retained in this matter, the attorney honor this Lien as inherent to the settlement and enforceable upon the case as if it were executed by him. I fully understand that I am directly and fully responsible to said doctor for all medical bills submitted for service rendered me and that this agreement is made solely for said doctor s additional protection and consideration of her awaiting payment. And I further understand that such payment is not contingent on any settlement, judgment, or verdict by which I may eventually recover said fee. The undersigned does hereby agree to observe all the terms of the above and agrees to withhold such sums from any settlement, judgment, or verdict as may be necessary to adequately protect said doctor above-named. Date Patient s Signature Date Insurance Adjuster s Signature Adjuster s Printed Name

8 250 Newport Center Dr, Ste 102 Newport Beach, CA Ph Fx Notice of Doctor s Lien Patient s Printed Name: Date of Accident: I do hereby authorize Olivieri Chiropractic Inc. to furnish you, my attorney, with a full report of the examination, diagnosis, treatment, prognosis, etc., of myself with regard to the accident in which I was recently involved. I hereby authorize and direct you, my attorney, to pay directly to said doctor such sums as may be due and owing for medical service rendered me both by reason of this accident and by reason of any other bills that are due this office and to withhold such sums from any settlement, judgment, or verdict as may be necessary to adequately protect and fully compensate said doctor. And I hereby further give a Lien on my case to said doctor against any and all proceeds of my settlement, judgment, or verdict which may be paid to you, my attorney, or myself, as the result of the injuries for which I have been treated or injuries in connection therewith. I fully understand that I am directly and fully responsible to said doctor for all medical bills submitted for service rendered me and that this agreement is made solely for said doctor s additional protection and consideration of his awaiting payment. And I further understand that such payment is not contingent on any settlement, judgment, or verdict by which I may eventually recover said fee. I agree to promptly notify said doctor of any change or addition of attorney(s) used by me in connection with this accident, and I instruct my attorney to do the same and to promptly deliver a copy of this lien to any such substituted attorney(s). Please acknowledge this letter buy signing below and returning to the doctor s office. I have been advised that if my attorney does not wish to cooperate in protecting the doctor s interest, the doctor will not await payment and may declare the entire balance due and payable. Date Patient s Signature The undersigned being attorney of record for the above patient does hereby agree to observe all the terms of the above and agrees to withhold such sums from any settlement, judgment, or verdict as may be necessary to adequately protect and fully protect said doctor above-named. Attorney further agrees that in the event this lien is litigated, that the prevailing party will be awarded attorney fees and costs. Date Attorney s Signature Attorney s Printed Name