1

ACCIDENT INFORMATION FORM Date Of Service: ______________

DOB:____________________ SSN: ____________________________________________

PATIENT NAME _______________________________________________________________

PATIENT PHONE # _____________________________________________________________

ATTORNEY NAME _____________________________________________________________

ATTORNEY PHONE/FAX # _______________________________________________________

DATE OF ACCIDENT _______________ WHO IS AT FAULT? _____________________________

AUTO INSURANCE CO. ________________________________ PIP EXHAUSTED? ___________

POLICY # ______________________ CLAIM # ________________________________________

BI __________ UM __________ PROPERTY DAMAGE $ ________________________________

ADJUSTOR: ___________________________________________________________________

FILMS DONE? ________________________PRIOR IMAGING? ____________________________

ALREADY SEEING A CHIRO? _______________ REFERRED BY ____________________________

2

PATIENT INFORMATION

Patients Name (Last, First, Middle Initial): _________________________________________________

Sex: M □ F □ Date of Birth: ___ / ___ / _____

Social Security Number: _____ / _____ / ______ Marital Status: Single Married (Circle One)

CONTACT INFORMATION

Mobile Phone: (____) ____ - ______ Email: _________________________________________

Home Phone: (____) ____ - ______ Work Phone: (____) ____ - ______

Address: ____________________________________________________________________________

____________________________________________________________________________________

EMPLOYER INFORMATION

Occupation: ___________________ Employer Name: _______________________________________

Employer Address: _____________________________________________________________________

_____________________________________________________________________________________

WORK STATUS

Full Duty □ Light Duty □ Off Duty Per Physician □ Unemployed □ Retired □

If you are NOT working full duty, how long have you been off work?______________________________

Have you had a work capacity assessment? □ Yes □ No

3

Are you disabled through Social Security? □ Yes □ No

DEMOGRAPHICS

Ethnicity: ______________________ Preferred Language: ___________________________________

PRESCRIPTION HISTORY

List Any Known Drug Allergies: ____________________________________________________________

List ALL CURRENT MEDICATIONS as follows:

Name Dose (milligrams, grams) Frequency Duration

SOCIAL HISTORY

Do you currently use tobacco products? □ Yes □ No If yes, quantity: ______________________

If past smoker, when did you quit? ______________ What was past quantity? _____________________

Do you currently consume alcoholic beverages? □ Yes □ No Quantity? _____________________

Have you ever been treated for drug and/ or alcohol abuse? □ Yes □ No

Highest Level of Education Received: _______________________________________________________

4

SURGICAL HISTORY

List any MAJOR EVENTS OR SURGERIES you have had by type, date and outcome:

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

PAST MEDICAL HISTORY

Bowel Disorders Osteoporosis

Cancer (Where) Pacemaker

Depression Polio

Diabetes (I or II) Psoriasis

Heart Disease Rheumatism

High Blood Pressure Seizures

High Cholesterol Serious Infection

Kidney Disease Stroke

Lung Disease Thyroid

Multiple Myeloma Ulcers

OTHER:

FAMILY HISTORY

Please list any illness, medical condition or death of immediate family members: ___________________

_____________________________________________________________________________________

PATIENT INFORMATION OF DIAGNOSIS

Briefly describe your main problem/complaint: ______________________________________________

_____________________________________________________________________________________

What was the date of accident? ___________________________________________________________

Please describe the details of your auto accident and answer questions in the boxes below.

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

5

Were you wearing a seatbelt? □ Y □ N

Were you the driver or passenger? □ Driver □ Passenger

Did you lose consciousness? □ Y □ N

Did you go to the hospital from the accident? □ Y □ N

Was it by an ambulance? □ Y □ N

Have you had the same or similar condition within the last 24 months? □ Y □ N

If yes, was treatment required? □ Y □ N

Describe when:

_____________________________________________________________________________________

_____________________________________________________________________________________

Notes:

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

6

Using the symbols below, please draw the location of your symptoms on the diagram and rank your pain

level from a 1 to 10.

XXX Pain 0000 Numbness

//// Aching **** Pins & Needles

If you have NECK PAIN, what percentage of your pain is _______% Neck and ________% Arm (Total

100%)

If you have BACK PAIN, what percentage of your pain is _______% Back and ________% Leg (Total

100%)

Mark an X on the line indicating the usual Degree of the Pain (0 meaning No Pain, 10 meaning Worst

pain) 0______1______2______3______4______5______6______7______8______9______10

7

What position/activity makes the pain worse and/ or better? Examples include: bending, twisting,

walking, laying down, sitting, standing, etc.

WORSE:

_____________________________________________________________________________________

BETTER:

_____________________________________________________________________________________

How long can you STAND with no or minimal pain ____________ minutes. WALKING DISTANCE with no

or minimal pain

0-50ft ______ 50-200 ft ______ 200-500 ft ______ 500+ ft ______ 1⁄2 mile+ ______

Do you need SUPPORT to help you walk? □ Yes □ No

If yes, what kind of support?

_________________________________________________________________

Do you wear a back and/or neck BRACE? □ Yes □ No

If yes, what kind of brace?

________________________________________________________________

List below the PREVIOUS PHYSICIANS (MD, DO, Chiropractor) you have seen for your main

complaint/problem.

Physician Specialty Dates Treatment

Indicate which DIAGNOSTIC TESTS you have had in evaluation of your main complaint/problem (include

dates). Examples include: X-ray, MRI, bone scan, myelogram, etc.

_____________________________________________________________________________________

_____________________________________________________________________________________

8

Indicate which TREATMENTS you have had in evaluation of your main complaint/ problem and if they

were helpful:

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

REFERRAL INFORMATION

So that we may keep your family physician or referring physician informed of your progress under our

care, please list the name and address of that physician. If you do not want your records forwarded to

this physician, please check this box: □ Please DO NOT send my records to my primary care physician.

Primary Care Physician: ____________________________ Phone: (____) ____ - ______

Address: _____________________________________________________________________________

Please mark below how you were referred to Tampa Back Institute.

Referring Physician: ___________________________ Referring Hospital: _________________________

Friend/ Word of Mouth ________________________ Internet ____ Insurance ____

9

HIPAA Medical Records Release Authorization Form

Who do you want your medical records to go to?

**Authorization for Use or Disclosure of Protected Health Information (Required by the Health

Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)**

1. Authorization: I authorize Tampa Back Institute to disclose my protected health information to

______________________________________________ (ex: attorney, chiropractor, etc).

2. Effective Period: This authorization for release of information covers the period of healthcare

from: ______________ to ______________ OR ___all past, present, and future periods.

3. Extent of Authorization: I authorize the release of my complete health record (including images and

labs).

4. This medical information may be used by the person I authorize to receive this information for

medical treatment or consultation, billing or claims payment, or other purposes as I may direct.

5. This authorization shall be in force and effect until ___________________ (date or event), at which

time this authorization expires. If left blank, consent will be effective for two years.

6. I understand that I have the right to revoke this authorization, in writing, at any time. I understand

that a revocation is not effective to the extent that any person or entity has already acted in reliance on

my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and

the insurer has a legal right to contest a claim.

7. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be

conditioned on whether I sign this authorization.

8. I understand that information used or disclosed pursuant to this authorization may be disclosed by

the recipient and may no longer be protected by federal or state law.

You have a right to receive a copy of this notice at any time upon request.

Signature of patient or personal representative: ______________________________________________

Printed name of patient or personal representative and his or her relationship to patient:

_____________________________________________________________________________________

Date: ____ / ____ / _____

10

PATIENT / PHYSICIAN AGREEMENT

PRESCRIPTION REFILLS

Please don't wait until you run out of medicine to call for a refill. In order to protect you, your doctor must review your medical

file before renewing a prescription. Please do not call for medications after hours or on weekends when records are

unavailable. It could take up to 48 hours after you call before your doctor can review your file and call in any prescription.

The files are reviewed and prescriptions are called to pharmacies at the end of office hours after all patients have been seen. A

written prescription is required for narcotic refills. I have read, understand, and agree with the above.

Patient/Guardian Signature:______________________________ Date:_______________________

MEDICAL RECORDS

Your records are kept in strict confidence as part of our permanent file. We will release copies only if we have your written

permission. We prefer to mail copies of records, but we will give them to you in person to hand-carry if time is critical. Please

give us at least 48 hours notice prior to coming in and picking up records as it does take some time to get things together for

you. I have read, understand, and agree with the above.

Patient/Guardian Signature:______________________________ Date:_______________________

STATEMENT OF FINANCIAL RESPONSIBILITY

I the undersigned realize that all medical and surgical charges incurred by me or my dependent/s are my financial responsibility.

All court fees, attorney fees, and other fees necessary to collect this amount are payable by me. I grant consent to Tampa Back

Institute to use and disclose my protected health information for the purposes of diagnosing or providing treatment and

conducting surgical operations. My protected health information includes demographic information which is collected from me,

created or received by my physician or another health care provider, and my employer. This protected information relates to

my past, present, and future physical and mental health condition/s. I can receive from Tampa Back Institute a copy of the

Notice of Privacy Practices prior to signing this document and understand it is subject to change. I understand that diagnosis

and treatment of me Tampa Back Institute may be conditioned upon my consent as evidenced by my signature on this

document. I have read, understand, and agree with the above.

Patient/Guardian Signature:______________________________ Date:_______________________

CONFIDENTIALITY

The physician will diagnose your illness according to your complaints, symptoms, test results, and medical history. In order to

treat the patient appropriately, the patient understands and authorizes treating physician and/or facility to obtain any and all

medical records relating to the patient and to communicate with previous physicians by any method that can assist with the

care of the patient. I have read, understand, and agree with the above.

Patient/Guardian Signature:______________________________ Date:_______________________

INDIVIDUAL PATIENT AUTHORIZATION

Name the people and/or organization and their relationship to you that are authorizing to use and/or disclose your personal

health information.

I CERTIFY THAT, TO THE BEST OF MY KNOWLEDGE, THE INFORMATION IN THE PATIENT INTAKE FORMS ARE ACCURATE.

Patient/Guardian Signature: ______________________________ Date: _______________________

11

6918 Gunn Hwy., Suite C

Tampa, FL 33625

813-803-0029 ** Fax 813-949-8919

Narcotic Pain Medication Policy

Please be advised that effective October 6, 2014, the Drug Enforcement Administration (DEA)

has imposed the Final Rule which effects the prescribing of hydrocodone combination products.

These products are now classified as Schedule II which means that they can no longer be called

into your pharmacy. If you are prescribed any hydrocodone combination product, you must

present a physical prescription to your pharmacy.

Our prescription refill policy, which was presented to you at your first appointment, requires

that you allow 24-48 hours for any refill request to be completed. With the new classification of

hydrocodone combination products, we will be unable to authorize refills after 3pm Monday

thur Thursday and 10am on Fridays. There will be NO refills granted Saturday thur Sunday. You

are required to provide government issued picture identification and provide signature of

receipt in order to pick up any narcotic pain medication.

By signing this document, you are acknowledging that you understand the DEA changes and the

adjustment of our narcotic pain medication policy.

_________________________ ________________________________ ____________

Patient / Guardian Signature Patient/ Guardian Printed Name Date

12

OFFICE OF INSURANCE REGULATION

Bureau of Property & Casualty Forms and Rates

Standard Disclosure and Acknowledgement Form Personal Injury Protection - Initial Treatment or Service Provided

The undersigned insured person (or guardian of such person) affirms:

1. The services or treatment set forth below were rendered. This means that those services have already been provided. Medical Services

2. I have the right and the duty to confirm that the services have already been provided.

3. I was not solicited by any person to seek any services from the medical provider of the services described above.

4. The medical provider has explained the services to me for which payment is being claimed.

5. If I notify the insurer in writing of a billing error, I may be entitled to a portion of any reduction in the amounts paid by my motor vehicle insurer. If entitled, my share would be at least 20% of the amount of the reduction, up to $500.

Insured Person (patient receiving treatment or services) or Guardian of Insured Person:

____________________________________________ ___________________________________________ __________________________

Name (PRINT or TYPE) Signature Date

The undersigned licensed medical professional or medical director, if applicable, affirms the statement numbered 1 above and also:

A. I have not solicited or caused the insured person, who was involved in a motor vehicle accident, to be solicited to make a claim for Personal Injury Protection benefits.

B. The treatment or services rendered were explained to the insured person, or his or her guardian, sufficiently for the person to sign this form with informed consent.

C. The accompanying statement or bill is properly completed in all material provisions and all relevant information has been provided therein. This means that each request for information has been responded to truthfully, accurately, and in a substantially complete manner.

D. The coding of procedures on the accompanying statement or bill is proper. This means that no service has been upcoded, unbundled, or constitutes an invalid or not medically necessary diagnostic test as defined by Section 627.732 (15) and (16), Florida Statutes or Section 627.736(5)(b)6, Florida Statutes.

Licensed Medical Professional Rendering Treatment/Services or Medical Director, if applicable (Signature by his/ her own hand):

Dr. Mark Perenich

Name (PRINT or TYPE) Signature Date

OIR-B1-1571 Pub. 1/2004

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of Claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree per Section 817.234(1)(b), Florida Statutes.

Note: The original of this form must be furnished to the insurer pursuant to Section 627.736(4)(b), Florida Statutes and may not be electronically furnished. Failure to furnish this form may result in non-payment of the claim.

13