aa new patient paperwork buford

7/28/2019 AA New Patient Paperwork Buford

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3420 Buford Dr. Suite E-780 Buford, GA 30519 Office: 770-945-7246 Fax: 770-945-7044

Personal Injury Form

This form must be filled out completely before treatment starts.

Patient Name: _____________________________________________ Date: ___________________________________

Insurance Company or Law Firm Name: __________________________________________________________________

Circle One: Med Pay Third Party

Claim or Case Number: _______________________________________________________________________________

Adjuster or Lawyer Name: ____________________________________________________________________________

Phone Number: __________________________________ Extension: _________________________________________

Fax Number: _______________________________________________________________________________________

Notice: Having insurance information is not a guarantee that they will cover your fees in full. Whatever your insurance

provider does not pay will be your responsibility. If you fail to keep in contact with the insurance company and your case

closes before our bill is paid in full, you will be responsible for your balance.

Patient Signature: ___________________________________________________________________________________


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Auto Accident Report Form

Patient Name: ___________________________________ ______ Time of Incident: _________ am or pm (circle one)

Date of Accident: _____/_____/_____ City of Accident: _________________________________________________

Street of Accident: _____________________________ Cross Street (intersections): __________________________

Road conditions at the time of the incident: (circle one) Wet Dry Icy Other: ___________________

Did the police come to the scene of the accident? (circle one) Yes No

Was an accident report filed? (circle one) Yes No

Were you taken to the hospital? (circle one) Yes No

Hospital Name and City: _____________________________________________________________________________

How did you get to the hospital? ______________________________________________________________________

Were x-rays taken? (circle one) Yes No

If yes, what was x-rayed? (circle one) Head Neck Upper Back Mid Back Lower Back Other: _________

The following questions pertain to you, the patient, and the vehicle you were in:

Were you seated in the vehicle? (circle one) Yes No

Were you aware of the approaching collision, or did the impact surprise you? (circle one) Aware Surprise

Did you lose consciousness (black out) upon impact? (circle one) Yes No If yes, for how long? _______________

How far is the top of the headrest/seatback from the top of your head? Approximately: _____ inches Above or Below

Were you wearing a seatbelt? (circle one) Yes No If yes, what kind? (circle one) Lap Belt Shoulder Belt

Vehicle Information and Velocity:

Vehicle Year: ___________ Make: ____________________ Model: __________________________

Was your car moving or stopped? (circle one) Moving Stopped

If your car was moving:

How fast were you going? Approximately _______ m.p.h.

Just before impact, the car was: (circle one) Slowing Down Speeding Up Constant Speed

Please explain the details of the accident to the best of your knowledge:


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Please mark the area of your symptoms:

On a scale of 0 to 10, zero being the lowest level and ten being the highest, how would you rate the effect your

condition or pain has on your daily functioning when you are at rest? (circle one)

0 1 2 3 4 5 6 7 8 9 10

On the same scale of 0 to 10, zero being the lowest level and ten being the highest, how would you rate the effect your

condition or pain has on your daily functioning when you are active? (circle one)

0 1 2 3 4 5 6 7 8 9 10


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Were there bleeding cuts cause by the accident? (circle one) Yes No Where? _________________________

Did the accident cause any bruises? (circle one) Yes No Where? _________________________

Where did the following body parts hit during the accident:

Head: ______________________________________________________________________________________

Chest: ______________________________________________________________________________________

R/L Shoulder: ________________________________________________________________________________

R/L Arm: ____________________________________________________________________________________

R/L Hip: _____________________________________________________________________________________

R/L Leg: _____________________________________________________________________________________

R/L Knee: ___________________________________________________________________________________

Other: ______________________________________________________________________________________

What was the cost of damage to the vehicle you were in? $__________________________________________________

Which (if any) of the following car parts broke during the accident? (circle all that apply)

Windshield Steering Wheel Front Seat Back Seat Side Window (R/L) Other:_______

Was the trunk of your body pointed straight forward at the time of impact? (circle one) Yes No

If no, which direction was it pointed, and by how much? _____________________________________________

Was your head pointed straight forward at the time of impact? (circle one) Yes No

If no, which direction was it turned, and by how much? ______________________________________________

The following questions pertain to the other vehicle involved in the accident:

Other Vehicle Year: ______________ Make: ________________________ Model: __________________________

Was the other car moving or stopped? (circle one) Moving Stopped

If the other car was moving:

How fast was it going? Approximately _____ m.p.h.

Just before impact, the other car was: (circle one) Slowing Down Speeding Up Constant Speed

If you have been involved in previous auto accidents, please list the year of each incident:

Please list any additional information not covered above that we should know about:

Patient Name (Printed): ________________________________________

Signature: ___________________________________________________ Date: _________________________


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Voluntary Irrevocable Physicians Lien

I, _________________________, hereby authorize and direct my attorney to pay directly to said medical facility such

sums as may be due and owing them for medical services rendered to me both by reason of this accident and by reason

of any other bills that are due to Buford Pain & Rehab and to withhold sums from any and all proceeds of such

settlement, judgment or verdict which may be necessary to adequately protect such medical facility. I hereby furthergive a lien on my case to said medical facility against any and all proceeds of such settlement, judgment or verdict which

may be paid to the attorney or me as the result of the injuries for which I have been treated or injuries in connection

herewith.

I fully understand that I am directly and fully responsible to said medical facility for all medical bills submitted by them

for services rendered to me and that this agreement is made solely for said medical facilitys additional protection and

consideration of their awaiting payment. I further understand that such payment on any settlement, judgment or

verdict by which I may eventually recover said fee.

I agree that this lien will be binding on any attorney who will represent me hereinafter.

Date: __________________ Patient Signature: ____________________________

Date: __________________ Witness Signature: ___________________________

The undersigned attorney 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 Buford Pain & Rehab.

Date: __________________ Attorney Signature: __________________________

Print Name: ________________________________

Address: ___________________________________

___________________________________________

___________________________________________

Phone: ________________ Fax: ________________


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Contingency Agreement

The following is a statement of our Contingency Agreement which we require that you read, agree to, and sign prior to any

treatment.

CONTINGENCY SERVICES:

We have agreed to accept your personal injury case on a contingency basis. This means that we have agreed to treat you for your

injuries while deferring your payments for services rendered until your case settles. We are extending you this credit based on the

stipulations below.

We require: A copy of your insurance card (auto)

A copy of your drivers license

A copy of the police report

The adjusters name and phone number

A copy of a credit card and credit card information written below.

REGARDING INSURANCE:

If you decide to use your health insurance as a backup form of payment, then please note the following:

- You are responsible for our fees if your insurance company decides to deny payment.

- You are responsible for any deductibles and co-pays that may apply.

Your insurance policy is a contract between you and your insurance carrier. Therefore, should your insurance carrier pay less than

you expected, or not at all, it is your responsibility to confer with them if you wish to dispute your claim. Such a dispute will not

affect your financial obligation to make timely payments toward your balance. You are ultimately financially responsible for the

services you receive, and payment to our office is neither contingent nor dependent upon your insurance company.

Our practice is committed to providing the best treatment for our patients, and we charge the usual and customary fees for our

area. You are responsible for payments regardless of any insurance companys arbitrary determination of usual and customary rates

ONCE YOU ARE DISCHARGED FROM OUR CARE:

Once you are discharged from our care, you have 90 days to pay your balance. Please note that when claims are settled via 3 rd Party

Insurance, you may receive payment for your settlement. It is your responsibility to pay our office any balance due on your account.

If we do not receive payment within 3 business days of a settled claim, then your credit card will be charged. If the credit card

transaction is denied, then interest on your balance will begin from the day of your first treatment at a rate of 20% APR plus a

processing fee of $100.00. Remember that we are accepting your case on contingency and extending you this credit until your claim

settles. Timely payment of a settled claim will void the interest.

If you have any questions about our contingency policy, please speak to the office staff.

____________________________________________________________________________________________________________

CREDIT CARD: Visa MasterCard Discover

CARD HOLDER NAME: _______________________________________

CARD NUMBER: ____________________________________________ EXP DATE: _________________

I have read and understand the contingency agreement. I agree to the terms, and I hereby authorize Buford Pain & Rehab to charge

any outstanding balance due to this clinic to the above credit card.

_______________________________________________ _________________________

PATIENT SIGNATURE DATE

aa new patient paperwork buford

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